One of the new realities of social media is that old news can be dredged up and spread around. In this way old memes can keep coming back to life like the Terminator, and we have to kill them over and over again.

The antivaccine crowd, for example, has their narrative of conspiracy and evil and their cherry-picked factoids to support their narrative. In their world vaccines don’t work and are all bad all the time, and only corporate evil and public malfeasance can support them. They scour the internet for anything to support their beliefs, and then splash it around as if it’s news.

In this case, they have resurrected a terrible survey from 1992. The survey was conducted in New Zealand by the Immunization Awareness Society. Unsurprisingly, when this anti-vaccine group surveyed their own anti-vaccine members, they found a higher incidence of disease among vaccinated children compared to unvaccinated children.

The Free Thought Project declares this to “prove without a doubt” that unvaccinated children are healthier. I don’t think they understand what the words “prove” or “doubt” mean.

Survey are, of course, highly problematic as scientific evidence. They are uncontrolled and subject to overwhelming confounding factors and bias. These can be minimized by being very rigorous in technique. No rigor is evident in this survey which relies upon a self-selected and biased population. We don’t even have access to the actual survey used, so really no conclusions can be drawn from the results.

By contrast, here is a published study that gathered information on over 17,000 subjects (compared to several hundred in the above survey), using a representative population, with full details disclosed. They found that the only health difference between vaccinated and unvaccinated children is that unvaccinated children had more vaccine-preventable diseases. That’s it. The study, however, only looked at allergies and other infections, but increases in allergies and infections is part of the anti-vaccine claim.

The second study quoted in the Free Thought article is also a survey, conducted by a German homeopath. Orac already deconstructed this survey, but here are the highlights: This is an online voluntary survey, so a self-selective group. Almost all respondents report that they use homeopaths, naturopaths, or chiropractors as their doctors and favor alternative medicine over mainstream medicine. There is no control group – the survey is just for the “completely unvaccinated.”

On other words – this survey is entirely worthless as scientific evidence. Also, ironically, the data shows an autism rate that is in line with the background rate in the general population. So even this crappy data cannot be used to argue for an association between vaccines and autism.

Conclusion

It is very telling that anti-vaccine groups and alternative medicine sites consistently reference terrible studies in support of their position. The two surveys discussed above are essentially worthless, yet they are touted endlessly by anti-vaccine sites, and I am sure we will see them turn up over and over again.

Scientific evidence is never perfect, especially in a messy area like medicine. The best we can do is look objectively at all the available evidence and try to come to the most reliable conclusion we can.

If you have an agenda, however, there is always plenty of low-quality evidence to cherry pick. Unfortunately, it takes work and some familiarity with the research to recognize cherry picking for what it is.

Social media campaigns spreading lies and misinformation over and over again can therefore be effective, even when they rely upon outdated and terrible information.

All we can do on our end is to continue the game of whack-a-mole, and perhaps hope that the general public will become more critical and savvy over time.

270 thoughts on “Health of Vaccinated vs Unvaccinated”

I’m glad you put chiropractors in the same category as homeopaths…
Almost everyone I know sees chiropractors, and there is NOTHING I can say to make them understand they’re being tricked into immediate relief (probably psychological)… And they get angry when I tell them I think the chiropractor is the main reason their backs never heal. Please write an article about chiropractors; give me some “ammo”. (PLEASE!!)
Sorry, off topic…

I have many friends who swear by chiropractors, and even more who swear by homeopathic remedies. (I don’t know much about chiropractors, but what I know about homeopathy makes it look like complete nonsense to me.)

But no one can be “tricked” into getting well (or, if they can, sign me up, that’s fine too) and if people with ailments which are out of the reach of conventional medicine find relief from pain, get well, feel better, I can’t see for the life of me what is wrong with that. Pain in particular always has a strong psychological component; many main-line pain clinics rely on this fact in formulating remedies, and this very often works for them and for their patients. Not enough attention, in my opinion, is paid to the therapeutic effects and the very real benefits of care, attention and other intangibles in the treatment of pain.

Your post sounds like you would like to take someone who actually feels relief from pain and talk them out of feeling better. That can’t be what you mean, since I gather that you are a physician.

Zorro,
I said they feel immediate relief; but my main point is that I strongly believe that “the chiropractor is the main reason their backs never heal”…
If they would just follow my advice, and stop seeing the chiro for a few weeks, and move more, as simply going for walks. But they insist on seeing their chiro at least once a week. After the session, they laugh about how much pain he subjects them too.
It saddens me to see them destroy their health, and waste money on charlatans.

When patients report that they feel better, it may be because….
– they may not actually feel better but simply report that that feel better in order to please the attentive practitioner who has gone to all the trouble of trying to help them.
– they may think they feel better without actually being better.
(There is an asthma study where patients said they felt better but objective measurements indicated they their asthma had not improved.)
– they may simply be returning to the mean.
(Patients tend to seek treatment when they are at their worst, meaning that they are likely to improve whatever they do)

Also the placebo effect, whatever the mechanism, is generally short lasting and generally disminishes with repeat treatments.

As for what the harm…
– the asthma study above shows that there is a potential for harm.
(If you think your asthma has improved but it hasn’t you may neglect to take your ventolin)
– there is the harm of using ineffective treatments in place of proven effective treatments.
– there is the harm of being potentially drawn into the world of alternative medicne world for the management of more serious conditions for which effective treatment is available
– there is the general harm of believing something to be true when it isn’t.

In summary, if all you have is the placebo effect, this means that the treatment doesn’t work.
Find yourself a scientifically based effective treatment.

If I feel better I feel better, and no one is going to talk me out of it. (Just as when I am in pain no doctor is going to talk me into the idea that I am not.)

I understand the anxiety that a patient may neglect effective treatments in favor of ineffective ones. But what about conditions (and so much back pain falls into this category) about which conventional medicine can do little or nothing? When there is no scientifically established effective treatment at all?

If I had such a condition (which I am grateful that do not) and I found something that made me feel better without doing any demonstrable harm (I imagine most homeopathic treatments would fall into this category, since as I understand them they are chemically inert) you will have a very hard time talking me out of the idea that I feel better, doctor, or that I shouldn’t feel better for some reason which is important to you (“believing something to be true when it isn’t”) but which may not be important to me.

Most of my friends who visit chiropractors have been advised by their doctors that nothing much can be done about their pain. If the chiropractor makes them feel better that is good for all concerned so far as I can see.

In short, you think Homeopathy helped you once when you have something that is manageable without medical intervention, so when you do actually get sick, you go see them first and it delays or even substitutes real treatment resulting in a lot of harm or even death (considered to be the maximum harm).

As for Chiros, the risk to reward ratio is just not worth it. They can do real harm with very little evidence for any kind of cure for most, if not all, of their claims. That, for me is much worse than Homeopathy.

Bruce: I think you are missing Zorro’s point. He is talking about relief of symptoms, not curing or prevention of disease. The Singh article pointed out the danger of substituting homeopathy for traditional medicine in the treatment or prevention of diseases. That has nothing to do with symptom relief.

Real harm from chiros? I guess, apart from the occasional “chiro-caused-a-stroke” anecdote, I haven’t seen that. I think the problem with chiropractic is that they seem to tend to hang onto their patients for many treatments and tend to sell preventive adjustments and such. But there is not much doubt that many patients experience significant relief of symptoms such as back pain from judicious use of chiropractic.

BillyJoe: When patients report they feel better, it may be because…they actually do feel better.

Neither of you have addressed the points I made in my post.
In that post, I have already answered the objections both of you have raised in your follow up posts, so all I am prepared to do at this stage is to suggest you go back and read my post again.
If, after you have considered all of these points, you still have an objection, please let me know, because I believe I have covered all bases.

“But there is not much doubt that many patients experience significant relief of symptoms such as back pain from judicious use of chiropractic”

This is incorrect.

Patients often feel less pain after chiropractic treatment, but this does not mean that the chiropractic treatment provided that relief. That is your fallacy – after this, therefore because of this.

Chiropractors often employ massage and physiotherapeutic techniques as an adjunct to their chiropractic manipulations. These have been shown to provide some benefit. Chiropractic manipulation has not.
The harm is that you pay out a lot in time and money for no benefit and potentially subject yourself to other forms of useless altmed practices promoted by the chiropractor, including anti-vaccination advice.

“If I feel better I feel better, and no one is going to talk me out of it. (Just as when I am in pain no doctor is going to talk me into the idea that I am not.)”
Maybe not. Maybe a chiropractor or a witch-doctor with some mumbo-jumbo may make you forget. If that is the case, you merely received was entertainment and distraction. Watch the 3 Stooges or some such. It’s cheaper and safer.

“He is talking about relief of symptoms, not curing or prevention of disease.”

I did not deny that the patient did not feel relief from symptoms. The danger in them thinking it was magic woo that cured them as opposed to regression to the mean or any other placebo effect gives them a false sense of security when it comes to treating something more serious.

“Real harm from chiros? I guess, apart from the occasional “chiro-caused-a-stroke” anecdote, I haven’t seen that.”

“When patients report they feel better, it may be because…they actually do feel better.”

There is a very big difference between feeling better and actually being better. Sufferers of major trauma often report feeling quite good despite very obvious evidence to the contrary. Even if they were better, you still miss the point mentioned many times above.

“Chiropractors often employ massage and physiotherapeutic techniques as an adjunct to their chiropractic manipulations. These have been shown to provide some benefit.”

I’ve never been to a chiropractor, so I know all this only second hand.

But if, as you are suggesting, massage and physiotherapeutic techniques can provide some measure of pain relief, perhaps more could be done to incorporate these techniques into main-stream medicine. This would keep patients like this out of the hands of chiropractors, if that is an anxiety.

BillyJoe7, can’t find the link you refer to…
Only finding mostly 10 year old studies.
HOW do I prove to the common people, that they should avoid the chiropractor. Many will even answer that their DOCTOR recommended it!?
Is there any easy to read page I can send them to? One that doesn’t look like a mickey mouse website with words such as “quack”, pictures of ducks, or filled with “donation” links such as http://www.sfsbm.org/. These websites look so amateurish and fake I just shake my head and close them within 5 minutes.

zorro – they already are. Physical therapists, physiatrists, and sports medicine doctors use these modalities. There is nothing that is legitimate and evidence-based that is unique to chiropractic. When chiropractors are strictly evidence-based, in my opinion, they are basically physical therapists.

BillyJoe: Your point is that when patients report they feel better it is because of one of three reasons: to please the practitioner; their incorrect perception of feeling better; or they were going to get better anyway. There is a fourth reason that you did not include, i.e., that the patient actually did feel better. Again we are talking about symptoms. If the patient once had pain and now they don’t have pain, that is “better.”

If a patient walks into a chiro’s office with back pain all hunched over and in spasm and in pain, undergoes “treatment” whether manipulation or physiotherapy or massage in the chiro’s office, and comes out walking upright and without pain, my conclusion is that the treatment in the office had something to do with it. There was no other intervention, no sudden regression to the mean.

Bruce: We’re not talking about “major trauma.” We’re talking about simple stuff like back pain. The document you reference states that the incidence of side effects is unknown, and it relates to neck manipulation. I wouldn’t send my 90 year old mom to a chiropractor for neck manipulation because there is the possibility of harm. But for the average not-very-elderly person with back pain, sure.

About vaccination topic, I have an anonymous confession… I know they work, I know how they work, why they work…
But, I have an extreme phobia of them… Injecting the virus into my blood just instinctively feels wrong. I’d recommend it to others, but I can’t bring myself to do it.https://en.wikipedia.org/wiki/Hepatitis_A_vaccinehttps://en.wikipedia.org/wiki/Hepatitis_B_vaccine
I’m supposed to get those in relation with my work. But I can’t. I just want to run away whenever it becomes reality.
It’s probably stupid, but I can’t do it I can’t do it I can’t do it I can’t do it….

The last few times I have been vaccinated for influenza, I have been amazed about how tiny the needles are. You really don’t feel.

Go, get vaccinated. Bring a big strong friend to hold on to. It is better than immune globulin injections. Something my husband had to get when someone in a sandwich shop he had had lunch turned out to have Hepatitis A.

“If a patient walks into a chiro’s office with back pain all hunched over and in spasm and in pain, undergoes “treatment” whether manipulation or physiotherapy or massage in the chiro’s office, and comes out walking upright and without pain, my conclusion is that the treatment in the office had something to do with it. There was no other intervention, no sudden regression to the mean.”
That reminds of the poor woman, hunched over her cane, walked into a hardware store and saw Joe the hardware store doctor. She walked out a few minutes later, straight as an arrow. He had given her a longer cane.

“There is a fourth reason that you did not include, i.e., that the patient actually did feel better”

What I’ve said twice now and can only repeat a third time, is that they will not have felt better because of chiropractic. They might have felt better for the other three reasons you mentioned, or because of physiotherapy or massage employed by the chiropractor, or for the psychological reason of having someone pay attention to them and doing something. But the chiropractic manipulation, itself, has no beneficial effect. That is what the evidence shows. That person needs to see a physiotherapist or a massage therapist and get a real physical effect along with the psychological effect. Or a counsellor or psychologist for a directed psychological effect. That will also avoid the potential harm of believing something that is not true, being given other treatments which have been proven not to work (ie homoeopathic and herbal remedies), and given information that is untrue (ie anti-vaccination advice).

I really do hope I’ve made my point clear now…

Placebo = does not work.
Chiropractic manipulation = placebo = does not work.
Find something that DOES work.

My reference to people with major trauma was illustrating the point that even people with obvious injuries can report feeling very good. Feeling good does not mean being good.

I don’t really mind if it is proven physical therapy, as Steve said, if all they do is that, then they are basically physical therapists… the problem is while they might be able to cure with some of the modalities they use, they have quite a range of non-science based medical techniques that cause much more harm than good.

ChrisH, for the A variant, “contains a live but attenuated virus”…
Anyway, if you’ve ever see an “extreme phobia”…. I could get violent. Last time I tried, I just had to abort when I saw it get within 20cm of me… Followed by months of nightmares. I don’t think I can ever get vaccinated again. 🙁

BillyJoe: You seem to have trouble with the definition of “work.” They feel better following their treatment by a chiropractor. Whether it is because of the attention or massage or physiotherapy or “manipulation” or all of the above that they get with visiting one provider. Having no pain after treatment = feeling better after treatment = hmmm, maybe what just happened to me helped my back pain.

References to homeopathy, herbal remedies, and anti-vaccination advice have nothing to do with their treatment by a chiropractor for their back pain.

Bruce: And my point is that the setting of “major trauma” has nothing at all to do with the scenario of a patient seeking chiropractic treatment for musculoskeletal low back pain. The patient is seeking treatment for their symptoms. Feeling good to them is having less or no pain. Feeling good = being good.

“HOW do I prove to the common people, that they should avoid the chiropractor. Many will even answer that their DOCTOR recommended it!?”

You will have an uphill battle, especially if their non-evidence based, non science trained doctor recommends it. Many doctors have no idea how to evaluate a clincal trial. Altmed has infiltrated academia, medical schools, and medical practices (BTW, that is why sfsbm is asking for donations – to help combat this infiltration of non evidence based treatments into these institutions).

You seem to have trouble with the defintion of “chiropractic”.
Once you have that definition right, you will see what I mean by “chiropractic does not work”.
And, yes, apart from chiropractic not working, chiropractors do recommnend homoeopathy, herbal treatments, and anti-vaccination advice.
You seem to be at pains to avoid acknowledging the harm that chiropractors do.

Dr.Joe. In medicine we have a very specific meaning of the word “work” – it means there is a specific effect above and beyond non-specific placebo effects. If you redefine “work” to include placebo effects, then everything works, and the term losing all meaning.

Steven: Symptom relief is defined by the person experiencing the symptom. If the patient goes to a chiropractor and comes out with symptom relief, they consider that the chiropractic experience “worked.” Whether it’s the manipulation or attention or massage or some placebo effect added on, the experience and the care they got at the chiropractor contributed to their improvement. They know that. I don’t think it’s necessary to break it down into the components of the experience, like massage works and heat works and attention works but manipulation doesn’t work. It’s all a package and an experience that many patients find beneficial.

I could not disagree more. It is very important to break down what components of an intervention are working, and which are window dressing. That is core to the science of medicine. Otherwise we waste resources doing things that do not add to efficacy, may contain unnecessary risk, and confuse future research.

Steven: Well, I guess we disagree. I think patients generally like the chiropractic experience because of everything that goes into it. The personal attention, the conversation, the demonstration of interest from the chiropractor, the massage, the ice/heat, the manipulation, the unnecessary x-rays. I suppose one could study each of the components that make up an hour session and see which could be eliminated and still have the patient experience symptom relief. But, if patient satisfaction is already fairly high and if patients report symptom relief from a chiro visit, then why would you want to do that except for academic interest?

(If you got into an expensive treatment that was introduced that the insurance companies balked at, that’s a different thing.)

I think there’s a lot of art that goes into the “science of medicine.” If medicine discounts the art aspect, the patient schmoozing, the physician knowledge and experience, the gut feeling, etc., it’s not really clear to me that this would be a better thing.

I find it funny that one of CAM biggest claims is that it addresses the cause and not just the symptoms, but then apologists fall back on arguments like DrJoe ie if it fixes the symptoms then why not!?

So if you trick the patient into thinking he’s better, you’ve done a good job?
I’m sure people could be convinced a good bleeding works; but that does not justify the practice.
Chiropractors cause damage. They maintain the injuries, and prevent the body from healing. They are charlatans and should be treated as such.

“I suppose one could study each of the components that make up an hour session and see which could be eliminated and still have the patient experience symptom relief. But, if patient satisfaction is already fairly high and if patients report symptom relief from a chiro visit, then why would you want to do that except for academic interest?”

Why bother with chiropractic? Just watch a Louis de Funès comedy or 3 Stooges. You may find you get the same, without the risks and the costs. Hey, they feel better so it works. What do you care if it’s pure placebo of distraction or entertainment and not bone crunching?

That is a cop out.
It’s not a matter of agreeing to disagree.
Steven is right. You are wrong. Sorry.
I invite you to read this whole exchange again and see if you don’t agree that you’ve been clutching at straws all along and ignoring important points that all of us have made that don’t read into your favoured narrative about chiropractic?

“I think patients generally like the chiropractic experience because of everything that goes into it. The personal attention, the conversation, the demonstration of interest from the chiropractor, the massage, the ice/heat, the manipulation, the unnecessary x-rays”

The point is that the actual “manipulation” – the actual chiropractic part of the variety of treatments that chiropractors use, and the reason chiropractic exists – does not work. Chiropractic manipulation can also occasionally do harm. Even if it does so rarely, this risk is unjustiable if the treatment has been shown not to work.
Again you seen to be at pains to avoid acknowledging the harm of chiropractic, although I do see that you’ve plugged the x-rays as unnecessary. Is that not a harm?

“I suppose one could study each of the components that make up an hour session and see which could be eliminated and still have the patient experience symptom relief”

It’s been done for the actual chiropractic manipulation and it does not work.

“But, if patient satisfaction is already fairly high and if patients report symptom relief from a chiro visit, then why would you want to do that except for academic interest?”

A number of reasons…
Time, cost, introduction to other unproven and disproven altmed treatments, anti-vaccination propaganda, believing something to be true when it is false, a false world view that makes you vulnerable to con artists and scammers.
But I’ve said all this before, so no doubt it will continue to have no effect on you.

“I think there’s a lot of art that goes into the “science of medicine.” If medicine discounts the art aspect, the patient schmoozing, the physician knowledge and experience”

So why not use that with treatments that have actually been shown to work?

“the gut feeling”

Perhaps I’m exaggerating a little when I say this, but intuition is almost always wrong. At best – and provided it is based on what we already know – it can form the basis of an hypothesis to be tested. And it needs to be tested – through the rigors of the scientific method. This is how we know what it true and what is false.

BillyJoe: You will notice, if you read more carefully, that I mentioned the “chiropractic experience,” not specifically the manipulation. It’s the whole experience that patients seem to like and find benefit from. Many patients do feel better symptom-wise after attending a chiropractic session or two or six. Regarding “harm,” we already addressed the unknown incidence regarding specifically cervical manipulation. I suspect there is less harm from chiropractic treatment of low back pain. Though I guess you think that their harm is that some of them espouse alternative opinions regarding things like homeopathy and non-vaccination. It’s up to the patient to follow that advice or not. Presumably, if they get propagandized by the chiropractor, their own family doc will provide the opposite viewpoint. Or do you think it’s up to someone to keep the patient out of hearing range of this propaganda?

Regarding time and cost, I would bet it’s a wash between six sessions of chiropractic and six sessions of physical therapy. And it’s not the physician responsibility to shield the patients from propaganda or prevent them from whatever “world view” they want to have.

Regarding the art aspect, the physician has to listen to the patient. If the patient reports success with chiropractic in the past and requests it again, the experienced clinician will recognize that the patient’s expectations have a lot to do with their healing. In the same vein, if the patient has tried multiple other modalities and found them to be of no benefit and suggests chiropractic because they have heard good things or whatever, perhaps the family doc will admit that it’s worth a try.

Regarding gut feelings, the experienced physician will be able to see and hear what the patient is saying and where they’re coming from healthcare-wise. If the physician understands that the patient is sort of on the alternative medicine side of the line and requests chiropractic rather than physical therapy, here again the physician will recognize the patient’s expectations and perhaps go with them. That’s what makes it artful rather than robotic.

The experienced physician will involve the patient in their own care. And again, we are not talking about treatment of disease. We’re talking about simple treatment of common symptoms.

Why bother with chiropractic? Just watch a Louis de Funès comedy or 3 Stooges. You may find you get the same, without the risks and the costs. Hey, they feel better so it works. What do you care if it’s pure placebo of distraction or entertainment and not bone crunching?

Curly: “I don’t know anything about chiropracty!”
Moe: “Everyone just grab a spine and get crackin’!”
Homer: “Hehe! Moe is their leader.”

In my opinion, you don’t have any reasonable arguments so you’re scraping the bottom of the barrell and coming up empty.
Your posts are loaded with empty arguments but I’ll give you just one example…

“If the physician understands that the patient is sort of on the alternative medicine side of the line and requests chiropractic rather than physical therapy, here again the physician will recognize the patient’s expectations and perhaps go with them. That’s what makes it artful rather than robotic”

That’s artful?
For a doctor to refer a patient to a chiropractor because he knows the patient prefers alternative medicine would be what you have called “robotic”. Not artful! How is there any art or difficulty in that. Doctor could you please refer me to a chiropractor. Sure here you go. An artful approach would be for the doctor to find ways of correcting the patient’s misconceptions about treatments they think might have helped them in the past whilst, at the same time, keeping them onside. It would just easy to go along with whatever the patient wants. To persuade them to use what will actually help them can, on the other hand, prove extremely difficult and require all the resources at the doctor’s disposal.
Okay, another empty bottom of the barrel argument….

“if they get propagandized by the chiropractor, their own family doc will provide the opposite viewpoint. Or do you think it’s up to someone to keep the patient out of hearing range of this propaganda?”

It’s not a matter of keeping the patient out of hearing range of propaganda, it’s a matter of them not even recognising it as propaganda.
And they may not even have a family doctor. Some use chiropractors as their only port of call for their health. Some chiropractors even encourage that view. But the point is that most patients will not even see it as propaganda. Going on their “chiropractic experience” with a friendly attentive practitioner, they are unlikely to even question his advice. If they do have a family doctor, they are not likley even to mention treatments or advice offered by the chiropractor.
And yet another empty bottom of the barrel argument….

“And it’s not the physician responsibility to shield the patients from propaganda or prevent them from whatever “world view” they want to have. ”

Responsibility or not, why wouldn’t a physician want to correct their patients’ misconceived “world view”? And it’s not a matter of “shielding” their patients from propaganda, it’s a matter of avoiding the undue influence of the charismatic practitioner. For an “artful” doctor with all the resources at his disposal, it will also be a matter of explaining that what the chiropractor is suggesting IS propaganda – that what he is suggesting has no evidential support.

“The experienced physician will involve the patient in their own care.”

Yes…by explaining to them the evidence, lack of evidence, or evidence against various proposed treatments and guiding them to an evidence based choice. Patients do not have experience and expertise. They need guidance from the experience and expertise of a evidence based physician. Otherwise what are you there for Joe? To pander to the patients wishes? Or to actually help them?

BillyJoe: You really don’t understand, do you? The “art” is recognizing that “correcting the patient’s misconceptions” is perhaps not something that the patient wants. The patient has developed their view of medicine and alternative medicine and believes that altmed is what they want to help them get better. The experienced physician will realize that “what will really help them” is perhaps what they want. The robotic response would be, “I know what is best for you because I have read the studies and this is what I will prescribe whether you like it or not.”

Wow. “Avoiding the undue influence of the charismatic practitioner.” Sounds sinister. But it really isn’t. Perhaps you would also like to keep the patient away from certain books that hold alternative views of medical care?

The artful, experienced, knowledgeable doctor will hold certain views of medicine and alt medicine. But he has to realize that he is there to help the patient. He gains the trust of the patient by doing what is in their best interests.

Obviously — and this is the key point — it makes NO difference at all in the health of the particular patient whether they get chiropractic care for their low back pain or 6 weeks of physical therapy or yoga or a combination of all three. The patient is going to get better regardless of the treatment they get. The relationship of the doctor and patient, however, is important. If the doctor realizes — there’s that gut feeling — that the paternalistic, I-know-all-and-certainly-more-than-you approach to a particular patient is going to damage their relationship, then he will not adopt that attitude. He will be open to and accepting of what the patient is asking for and will discuss it in an open accepting manner because he knows IT MAKES NO DIFFERENCE. Either treatment will work.

Certainly, if the patient were to broach the idea of using chiropractic for a condition the physician realizes might REQUIRE surgery or other modality or for treatment of a disease, this would be the time for education and convincing because it would be in the best interests of the patient to have the non-chiropractic treatment. But when it makes no difference, it makes no difference.

“An artful approach would be for the doctor to find ways of correcting the patient’s misconceptions about treatments they think might have helped them in the past whilst, at the same time, keeping them onside. ”

Important enough to repeat. there’s a misconception that the patient might know best. I feel a good doctor does the right thing, and not the thing the patient thinks is right.

@DrJoeinCA – by your reasoning if I suffer extreme back pain, but drink enough alcohol to take the pain away, I’ve found something that works?

“I feel a good doctor does the right thing, and not the thing the patient thinks is right.”

Wow. That’s pretty arrogant, and in addition it is impossible.

Doctors do not override the opinions of patients in this country, unless the patient has been declared incompetent in a court of law, and then he has to deal with the conservator. What are you suggesting? That a physician prevent an adult patient from consulting a chiropractor? How exactly do you suggest this be done?

If a physician feels strongly that physical therapy would bring better results than a chiropractor in a case of, say, low back pain (and I believe that data is not all that clear on this point) the physician had better be prepared to do a sales job on the patient, and must also be prepared to lose.

“Doctors do not override the opinions of patients in this country, unless the patient has been declared incompetent in a court of law, and then he has to deal with the conservator. What are you suggesting? That a physician prevent an adult patient from consulting a chiropractor? How exactly do you suggest this be done?”
Same as when a patient says that Vicodin will help him with his backache. That’s the patient’s opinion. I am overriding it and won’t prescribe it for him. How arrogant of me!

Doctors are highly trained professionals. A professional does not mislead a patient and suggest remedies for which there is no supporting science. A good doctor wouldn’t recommend homeopathic remedies for the same reasons.

While a patient has some say in how he or she is treated, ultimately it’s the responsibility of the Doctor to determine the proper course of treatment. While some of this should be tailored to the patient, it shouldn’t’ go beyond unscientific treatments.

It’s similar to a responsible financial advisor not recommending a client practice feng shui in order to bring in financial prosperity.

BillyJoe: And I guess you have not figured it out yet that some things just don’t make a difference, huh? When a doctor finds himself in conflict with his patient about something that doesn’t make a difference, it’s time to step back and determine whether the doctor/patient relationship or “being right” comes first. You obviously don’t get that part. The objective is to help the patient recover. Some people never get that, and they would rather “be right” than do the right thing for the patient.

Weing: Vicodin? It depends on the patient, on the exam, on the general circumstances. Pain is a subjective thing. It may be that arrogance is preventing the physician from giving the patient Vicodin because he considers pain a part of life and adopts the “suck it up” philosophy of treating back pain. Perhaps the patient doesn’t feel the same way. Gee, maybe compromise is worthwhile.

Grabula: But what does the doctor do when the patient requests chiropractic as “the only thing that has helped in the past?” Argue with the patient that it really didn’t help them in the past because the studies show…?

More like the client wanting to buy GE and the advisor recommending AMZN. Both are gonna work.

” Argue with the patient that it really didn’t help them in the past because the studies show…?”

Why argue at all. As a responsible doctor you explain to the patient where their perception has gone wrong. The patient has the option of going elsewhere to get his referral or to find another doctor who might be willing to kowtow to his misconceptions.

Both AREN’T going to work, that’s what these guys are trying to explain to you and zorrobandito. You’re misconception is believing that 1 – the patient knows best and 2 – that co-operating with the patience ignorance is also best for the patient.

Grabula: The patient comes to see the doc and says that chiropractic DID work in the past and he wants to try it again. Same back pain he gets every spring when he starts working in his garden, and chiropractic works every time. You expect the doc to tell him that it didn’t work? You want the doc to communicate to him that he is ignorant and has misconceptions?

Here’s a better idea. Say ok to the chiropractic. The patient will feel better because, based on his prior experiences, chiropractic will help relieve his symptoms. The patient will feel better about the doc because he will see that the doc is listening to him and respects his opinion about how his body reacts to stuff. Win win. And when there is another interaction in the future when the doc really needs to communicate with the patient about making a difficult choice, the patient will listen.

It is most assuredly NOT a misconception that patients frequently know what works for them and what doesn’t. How many times have you gone to a doc and you know what is wrong and what treatment has worked in the past? How pissed are you when the doctor doesn’t listen to you, and how bad do you feel about the encounter with the doctor?

This is not brain surgery or diabetes treatment. This is a self-limited symptom of low back pain that will get better no matter which treatment is used. And it will get better faster if the patient is allowed to have a say in their care and treatment rather than being pissed at the doc who wouldn’t listen to them.

Wake up to 20 more comments and DrJoe is still rattling out the same argument and does not seem to understand the basics of what we are arguing. The What’s the Harm argument simply does not hold up in the long term. It might work for one or two people but ultimately it does MORE harm than good.

” When a doctor finds himself in conflict with his patient about something that doesn’t make a difference, it’s time to step back and determine whether the doctor/patient relationship or “being right” comes first. ”

See what I mean.
You haven’t yet managed to read properly anything I (or anyone else) have written.
What did you think I meant when I said, and I quote:

“An artful approach would be for the doctor to find ways of correcting the patient’s misconceptions about treatments they think might have helped them in the past whilst, at the same time, keeping them onside.”

Now read the whole thing again – and properly this time – before responding again.

“Both AREN’T going to work, that’s what these guys are trying to explain to you and zorrobandito. You’re misconception is believing that 1 – the patient knows best and 2 – that co-operating with the patience ignorance is also best for the patient.”

I’m not saying that at all. I’m saying that patients have the power to consult whomever they choose, be it you or a chiropractor or a witch doctor, whether they “know best” or not. A patient whose lower back pain has been relieved, over and over, by a chiropractor has conducted a tiny non-scientific experiment of his own, and now will consult the chiropractor for lower back pain every spring.

If you as a physician wish for any reason to discourage this behavior you’re going to have to come up with an alternative which works at least just as well, together with an argument as to why your alternative is better. Most people will not listen, but some might.

Telling your patient that your idea is better simply because “it is better to believe the truth than falsehood” may not get you very far, especially if what you recommend doesn’t work as well.

A friend of mine with shoulder trouble recently asked me if he should go to a chiropractor. I described chiropractic as ‘back-rubs with magic’, suggested they look it up its origins on Wikipedia, pointed out that anyone could set themselves up as a chiropractor, and suggested they go to a qualified physiotherapist. Which they did.

“An artful approach would be for the doctor to find ways of correcting the patient’s misconceptions about treatments they think might have helped them in the past whilst, at the same time, keeping them onside.”

The artful approach is to see whether the patient has misconceptions that need “correcting.” If the patient tells you that they received symptom relief from chiropractic many times in the past, that they believe in the benefits of chiropractic, that they do not want to do physical therapy because it has not worked, etc., etc., it does not behoove you to “correct” this. The fact that the patient has gone to chiropractic and received benefit on more than one occasion means that ship has sailed. The only way to “correct” them would be to tell them they were deceived, scammed, taken advantage of, because YOU know that it couldn’t possibly work. As Zorro says, the patient did their own little non-scientific experiment.

So the artful physician lets it go, complies with the patient request, and moves on because — and I need to repeat this I suppose — IT DOESN’T MAKE A DIFFERENCE in this case. You really don’t get that part, do you? There are some things that just do not make a difference.

The object is to work WITH the patient to get them better whether you think their approach is unscientific or not as long as it does them no harm.

“So the artful physician lets it go, complies with the patient request, and moves on because — and I need to repeat this I suppose — IT DOESN’T MAKE A DIFFERENCE in this case. You really don’t get that part, do you? There are some things that just do not make a difference.”

I take issue with a doctor lying to their patient, e.g. telling them homeopathy works because it “worked or them”. I understad that you want to maintain rapport w/ your patients, but don’t you have some responsibility to tell you patients the truth? I think that one of the reasons that we’re burdened with this nonsense is the quasi-approval from many in the medical community. You don’t have to be rude about it, or tell them they were foolish etc. Condescendingly patting people on the head and in the process helping perpetuate the snake-oil industries seems to me a bad trade off.

“The object is to work WITH the patient to get them better whether you think their approach is unscientific or not as long as it does them no harm.”

But the sum of this sort of approach does harm. Lowering scientific standards in the medical community encourages people to use nonsense to treat real medical conditions. I guess at some level this is like antibiotics – some doctors may feel an individual vs. group conflict. I’d prefer e try to eradicate “treatments” that have shown time and time again to have no effect.

Steve12: The patient is not asking the doc whether or not he supports chiropractic. In fact, many patients know that the doc does not support chiropractic. The patient is not asking the doc for scientific studies. The patient already has the experience that his back pain was relieved by going to the chiropractor. The patient is asking for the doc to say that it’s ok to use a chiropractor. And when the doc tells the patient that it really won’t make a difference what modality is used to treat their back pain which is self-limited anyway, and sure he can give it a try if it’s worked before but the doc wouldn’t recommend it as the first-line treatment, then the doctor-patient relationship is honest and open. Everyone but BillyJoe is happy.

SteveA: Sure, “correct them” that what they experienced over and over again was not really happening. As with many other situations, one has to pick one’s battles. In a situation where IT MAKES NO DIFFERENCE what modality is used, battling is often not worthwhile and can sometimes damage the relationship. In situations where it does matter, then communication of the “proper” treatment is appropriate.

DrJoe, yes, that is my main thought about chiros: they maintain injuries by their thoughtless manipulations; moreover they keep patients from seeking real help. They are a danger to society, and have somehow become mainstream.

Nitpicking,
it’s everything: from the needles themselves, as well as the fear for air bubbles, injecting live organisms into me, getting an infection, etc. I’m (was :(… ) a nightmare for nurses: “wait! wait! wait! wait! wait! Are you sure there’s no air in it? -ok ok…” “WAIT! WAIT! WAIT! STOP! Is that needle still clean? I mean, I’ve been stalling you for 15 minutes already… I’m really sorry… Can’t we get a new one? PLEASE? Ok go for it…”
“NO! STOP! DON’T TOUCH ME! *breathing heavily*- ok ok I’m ready this time….”
“NOOOO! STOP! Where do I land when I faint? I KNOW I’m gonna faint. So I need to know where I land… – ok, ok, let’s do this…. NO! NOT SO FAST! I don’t wanna do this. Is this reeeeaaally necessary? Can’t I just be careful?”
(and so on, until I either get it and faint, followed by the nightmares, or I simply abort as the last few times… It’s also quite embarrassing..)

Unfortunately, the internet has given the rabid idiots an unfettered voice to spread their paranoid poison about vaccinations. So one finds are too many babblers making false claims about something they have no expertise to evaluate.

That sounds reasonable if you’re honest with them, and of course they’re free to do as they choose when they leave your office.

But you’re a little inconsistent in what you’re saying, so I’m not really sure where you’re coming from. YOu sort of intimate that you believe chiro and homeopathy work, then you kind of back away a bit. This is sort of like the GW discussion I was trying to have with you. I wanted to identify the basis in the literature for your assertions, but you kept obfuscating so I gave up.

This study is essentially worthless to begin with since it is a survey, but I dissected it a few years ago for fun. One of the things I noticed was that they supposedly had a lot of parents that vaccinated their first or second child, but not their last. Now of course there are still a ton of confounding factors, but I thought that data might be marginally interesting since it controls for genetic factors and some types of parental bias. So I looked in the results section …. nothing there. The authors purposely excluded the only comparison that contained a shred of objectivity. And for all we know that data still supported their conclusions, but they aren’t competent enough to even realize it.

When the anti-vaxxers learn how to design a study on par with my 8th grade science fair project, I’ll pay attention.

Dr.Joe is giving a bit of a contrived and limited example, I think to force his point. He is also giving false choices.

In reality every patient is a little different. But what they all have in common if they are sitting in my office and asking my advice is that they are sitting in my office and asking my advice.

It is possible to convey to a patient what I think about what the scientific evidence says, the plausibility of a treatment, and whether it is worth trying or continuing, without challenging their experiences. If they are interested I am happy to discuss with them how placebo effects can make something seem like it works when in fact it is adding nothing. I can also discuss with them alternatives, like back exercises and hygiene, that are likely to be safer and cheaper.

All of this has to be individualized to the patient – what are they asking me for, what is the therapeutic relationship, what is the exact context of the treatment and what options are there.

But I am always 100% honest with patients. I never lie to them or patronize them. I give them the information they need to make informed decisions.

Steve12: My experience is that low back pain is generally going to get better no matter what the intervention. Chiropractic experience, PT, massage, yoga. They all relieve symptoms and make the patient feel better. It makes no difference what the patient uses. The doc can make suggestions, but so can the patient. Let them work together.

I’m not concerned at all about “supporting the industry” or bringing chiropractic into the mainstream of medical practice. It just doesn’t matter.

I object when I see any practitioner up-sell procedures, whether it’s medical practice, podiatry, chiropractic or whatever. That kind of stuff is wrong. Plain old run-of-the-mill chiropractic for low back pain is fine and harmless and has its place.

StevenNovella: I feel the same way. If patients ask for advice, the physician can give his opinion and impart education and let the patient make their own choice. If, however, the patient is a child of the 60s, grey pony-tailed, no-nukes, power-to-the-people, university town, Ralph-Nader-is-a-god sort, and has made up their mind about alternative medicine and experienced benefit from it and doesn’t want to hear the other side, the physician should move on. All individualized to the patient.

I think *most* lower back problems come from a lack of activity.
Walking more, sitting right, not spending too much time sitting in front of laptop.
And it’s free. Go for a walk every day for a couple weeks; and mind your sitting posture… Just to see if it helps… Or they can just pay a chiro every week for years for a short lived illusion… In my opinion, a chiro is not worth much more than waving a magnet or drinking colored water that’s been shaken on a bible.

Yes, I know, I know, you are talking about the “chiropractic experience”.
But you are yet to acknowledge that the actual chirpractic treatment does not work.
And you are still at pains to avoid acknowledging the harm of chiropractic.

Going into an office and getting the chiropractic experience, and then reporting that you feel better does not mean that it worked. It is well known that pressure receptors inhibit the perception of pain receptors. So a massage or whatever might simply be temporarily masking pain, while leaving the problem there or making it worse. Asking people how they feel immediately after an experience is also well documented to be a terrible measure of efficacy of a treatment, they almost always report improvement. For example a patient can say they feel stronger without any improvement in measured muscle strength or a patient can report improved asthma symptoms with no change in measurable V-O2, I am pretty sure that Steven has written about this effect on this blog. Anectodatlly, I coach a running team and a participant complained of shin splints, I said that rest is the only way that they heal. Unfortunately, their chiropractor sold them some compression stockings and they reported feeling better all week and wanted to do this weeks’ run. I explained that pressure masks pain, it will feel better but the damage is still there. A week later, the runner experiences pain even while not running. This, my friends, is the harm. People will think that the doctor doesn’t care or won’t do anything because the doctor just says to rest while the chiropractor will have a whole dog and pony show with fancy stockings and a pseudoscientific narrative. Now my runner’s tibias hurt worse and will take even longer to recover. Still won’t listen when I say to rest. Unsurprisingly, no one listens when I say to see a doctor. I’m not a physician, but they are constantly asking me about various aches and pains that come with newbies to long distance running, I always tell them to see a doctor and I summarize the evidence in the literature to the best of my knowledge & experience.

BillyJoe: I have not backtracked. I have always said that the chiropractic experience works for some people. I didn’t say it’s the only recommended treatment, and I didn’t say it’s the only treatment. I specifically said that it’s the whole experience that has the effect, and I didn’t say that I knew what percentage manipulation as part of the experience had on the total effect. The desired effect is pain relief, and the chiropractic experience does provide pain relief to many people.

Chiropractic “treatment” includes all the components of the experience. And it works.

You are correct. I do not acknowledge that chiropractic does harm. Certainly, medically it does no harm other than some ill-advised neck manipulations that went south. There is zero harm in treatment of low back pain medically. If the individual chiropractor chooses to present the individual patient with what you term “propaganda,” that’s up to them. Let the patient decide what to read and what to listen to, unless your goal is to keep the patient away from exposure to such material. If the chiropractor presents incorrect information that is more persuasive than the patient’s family doc, shame on the doc.

Now, why would you ask me whether the videos show “effective treatment?” Better you ask the patients whether what the chiropractor did relieved their symptoms.

All that can be had with science-based medical treatments and without all the baloney that comes with chiropractic, including the part about manipulation. As mentioned before, one doesn’t have to waste money on the increased overhead that comes with chiropractic, they don’t have to accept the additional BS baggage that comes with chiropractic, and they can be free of the bad advice chiro’s often give (ie, anti-vaccination, bogus nutrition advice, subluxation, referrals to other CAM therapies, anti-medicine sentiment, etc).

When it comes down to it, the components that actually work with chiropractic can be had with a halfway decent massage for a fraction of the price, without all the baloney that comes with it, AND minus the risks that chiropractic also carries with it.

I would like to present an anecdote for what it’s worth,about a friend of mine who favored ‘holistic’ treatments,but also used conventional medicine.This is the type of “Where’s the harm?” scenario that comes up often:
My friend developed a tumor (supposedly benign) in one ear,that was causing pain and hearing loss.It was removed,but the surgeon scheduled her for regular checkups to monitor the potential regrowth/complications.
Instead of seeing the surgeon for monitoring,my friend instead relied on advice from a chiropractor,and alternative medical advice from a trusted massage therapist,who apparently was deeply steeped in various forms of woo. She also was almost fanatically a defender of Dr. Oz,and his dodgy approach to medicine.
The sad truth is,that she had a recurrence of the tumor,and this time it was determined to have spread widely,and required major,and disabling surgery,and they were very concerned that it might have spread further,and that proved to be true.
She admitted to me guiltily one day (blaming herself) that she should have not skipped the follow up monitoring of the original surgery,but she felt like she was on top of her situation with the ‘holistic’ advice that she was relying on from those well meaning,but clueless people,but the damage was done,and eventually she did succumb to the disease.
Would she have lived otherwise? I just don’t know,but I think her odds would have been much better had she listened to those who actually understood the situation,and were in a more informed position to guide her actions. It’s quite possible that earlier intervention might have saved her from not only the disfiguring and life changing second surgery,but might have caught the tumor early enough to prevent it’s spread,and ultimately her death.
But hey,the patient always knows best… right ?

” But what they all have in common if they are sitting in my office and asking my advice is that they are sitting in my office and asking my advice. ”

This is my ultimate point. As a doctor – it’s lazy to just go ahead and tell people it’s ok to indulge in woo if it ‘does no harm’ or ‘appears to make them feel better’. It’s not only lazy, I think it’s unethical.

The harm it does at the very least is continue to support garbage masquerading as medicine. Regardless of the perceived effect it’s tantamount to giving the ok to pursue say homeopathy since it seems to make the patient feel better. While I agree that each patient should be approached differently it doesn’t mean a doctor can’t be at all times honest and stick to his guns when it comes time to hand out referrals for example. If I were a doctor I wouldn’t refer patients to a chiropractor for the same reason I wouldn’t refer them to a homeopath. There are more ethical and science based options out there.

Steve12: I will repeat until you get tired of reading it. It is the whole experience that benefits the patient.

My understanding of “manipulation” is that the chiropractor feels there are minor deformities in the spinal joints that they “adjust.” I have no idea how many patients with low back pain who see chiropractors have these deformities or how much pain this causes or how many benefit from manipulation. If there is a minor subluxation and that is causing pain, adjustment would help that. But again, who knows how many patients have this?

Oh, in case I didn’t mention it, IT’S THE WHOLE EXPERIENCE THAT BENEFITS THE PATIENT.

Steve12: Since you seem to focusing on the manipulation aspect, you do realize that physical therapists also use spinal manipulation, don’t you? And you do realize this is an accepted part of physical therapy for low back pain and is safe and effective? Just checking. Because if you want to send the patient to PT rather than chiropractic, you should be aware that they may be getting the old manipulation treatment.

“I will repeat until you get tired of reading it. It is the whole experience that benefits the patient.”

I get that you think this. YOu can stop repeating it, seriously, to save yourself the carpal tunnel. People like attention from a treater, basic massage/ human touch, etc – and it makes them feel better. I’m sure this is true. I’m just not that interested in it so I’m not asking about it.

Physiologically, what are the deformities that chiropractics adjust for?

“And you do realize this is an accepted part of physical therapy for low back pain and is safe and effective?”

Which is it? The whole experience or the physical therapy?

Plus, as an added bonus:

“If there is a minor subluxation and that is causing pain”

You do realise that Chiropractic “subluxation” is woo? Taken directly from wikipedia on the subject:

“In May 2010 the General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, issued guidance for chiropractors stating that the chiropractic vertebral subluxation complex “is an historical concept” and “is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.””

Your claim that it is the whole experience that produces perceived benefit is an unsupported claim. You also claim it is not important to even research the question, so I guess you are happy with the assumption. This is the basis of placebo medicine, which is not legitimate in my opinion.

There is absolutely no reason to believe that you cannot get the entire placebo effect from a legitimate patient interaction, with only science-based recommendations, and absent any hocus-pocus. In fact, there are studies that show what matters most for the non-specific therapeutic benefits is just a positive interaction, not the empty ritual that accompanies it.

You really should read my articles on placebo effects. The reporting of a benefit is not the same thing as an actual benefit. If all you are interested in is making money from fooling patients into thinking they feel better, then anything goes. If you want to actually help patients, then we need evidence.

I have to pretty much agree with DrJoe. I’m not here to argue the science, just let you know that your dismissing something that has helped many people. I know you science guys dont like to accept anecdotes as evidence but hear me out. 2 years after injuring my back lifting something i put in a year of physio which did nothing for my lower back pain. I decided to try a chiropractor. After 3 visits to the chiropractor suddenly the pain disappeared. Initially it would last for 2-3 days pain free, but as he worked on strengthening my core muscles too my spine became more and more fixed permanently, locked in place. Now i’m no medical expert but the chiropractor clicked something back in (some kind of vertebrae he said) that was out of position, the kind of click you hear when your fingers crack or stretch your neck except the pain id had to varying degrees for 3 years was gone. It felt incredible, not something imagined by placebo treatment. This had been a continuous spasming pain that sent weird numbness and tingles all down my legs all suddenly gone. His conclusion was the misaligned spine was putting pressure on spinal nerves affecting feelings in my legs and directly causing direct back muscle pain. It seems plausible to me. Initially the fixes lasted just a few days but as we trained my muscles it lasted longer and longer until as of now it became fixed. I also started lots of walking on his recommendation. Plus as an added bonus i worked out how to click it in myself, so no more expensive chiropractor bills!. But Im telling u when i click it that pain goes away. Absolutely no placebo there. Why would i trick myself when i click my own back…that would be very strange behavior indeed.

Of course there are definitely good and bad chiropractors in that some actually train you to strengthen your core muscles (usually the cause of spine problems) so once its clicked in it will stay where its supposed to be whereas others just click the spine in and i guess hope for repeat visit because they didn’t prepare the muscles to support the fixed spine position. Trust me Im not an anti vaccer loon and will absolutely accept where evidence points to. But sometimes we update our knowledge of science and what we knew 20-30 years ago becomes updated or is added to/broadened or even changed as new evidence and theories comes to light. Look at nutrition. The now obsolete scientific evidence of lowering fat intake to prevent heart attacks has been disastrous for a generations health resulting in higher strokes and heart disease than ever before. We now know there is good cholesterol and not all fat is bad for us.

I think to call chiropractors quacks and charlatans (though im sure there are some) is being dismissive of something that needs to be understood more, perhaps even regulated to weed out the actual charlatans and give the ones who do provide genuine back pain releif and prevention a respected platform of possible alternative treatment. Just my 2 pence guys!

I had knee replacement surgery three weeks ago, so pain is on my mind. And more than my mind, though things are certainly getting better.

Pain is a complex phenomenon, having both a physical and an emotional component. We are all familiar with stories of football players or soldiers being unaware, until later, of serious injuries, because their minds were taken up with the matter at hand, adrenaline was in the picture, and so forth. Physicians who undertake to manage intractable pain do not confine themselves to chemicals, but use a variety of modalities, of which sympathy, attention and human contact are not the least valuable.

Pain is also difficult because it is so hard to measure objectively. Very largely we have to take the patient’s word for it.

If a patient reports pain relief from, say, massage, this is not necessarily “woo.” The therapist used touch, perhaps warmth, certainly encouragement, candles, scent, music, along with more measurable tools such as muscle relaxation techniques, to attack they psychic component of the pain.

Because I still do have some pain, I am not in the mood to have some physician tell me that I do not. (To be fair, and lucky for them, no one has tried that yet.) And if I feel better, I’m not very receptive to some physician who tells me I don’t, either.

This personal bias probably colors my comments, but it might be useful for you gentlemen to hear from a patient on these topics.

Bruce: We’re not talking about their claims that “subluxation” causes disease. We’re talking about the treatment of back pain. Don’t confuse the two. Manipulation is now a part of the physical therapy experience, chiropractic experience, and osteopath experience. That’s three of the most frequent treaters of back pain who have adopted manipulation as a helpful tool in the treatment of low back pain.

Steven Novella: What hocus-pocus and empty ritual are you are talking about? Is it the heat, cold, massage, conversation, interest, manipulation? That sounds a lot like pretty good therapy for low back pain to me. “Fooling patients into thinking they feel better?” Are you saying they don’t feel better? Are you saying they are fooled into thinking their pain is gone when actually it is still there?

Steve12: I don’t know what a physiological deformity is. Manipulation is a common therapeutic component of the care of back pain. If you’re not sure of the physiological causes for pain and pain relief, you could probably look it up.

“Steve12: I don’t know what a physiological deformity is. Manipulation is a common therapeutic component of the care of back pain. If you’re not sure of the physiological causes for pain and pain relief, you could probably look it up.”

So your basis for saying that it is effective is your patients’ response to treatment, not controlled experiments.

If that is the case, you really have no basis for saying what part of the total experience confers the benefit, right? The adjustment might do nothing beyond providing the comfort of touch – you really can’t say one way or another simply on the basis of your patients’ report.

Steve12: Yes, my basis for saying that it is effective is the patient response. If the patient has less back pain following treatment, they have reached their goal. Often, when patients go to PT or chiropractors, they are asked what their goals are and what they expect the treatment to do for them. If they go in with pain or limited motion, their goal is relief of pain and increase in motion. If they come out of the treatment — PT or chiropractic — with less pain and more motion, their goal is reached. Their pain is no more. Gone. On the other hand, if they do not satisfy their goal, their conclusion is that the treatment did not work.

I already said many times that there is no way of knowing what part of the total experience confers the benefit. I even shouted it a couple of times. I don’t think that the adjustment is at all a “comfort of touch.” It is pretty forceful, sudden, and thrusting. Massage is much more comfortable than that. But adjustment/manipulation is a very common modality among low back pain treaters for some patients with low back pain.

Dr.Joe – you are drifting in what you are referring to. So let me clarify what I am saying (which, by the way, is extensively covered here and on SBM if you are interested)

You were defending using elements of treatment that have not been demonstrated to provide benefit above placebo effects. You maintain, without evidence, that the “entire package” is somehow necessary.

I am objecting to specific things in your position:

– That we do not need to unpack which elements of an intervention work or do not work. I strongly disagree. The science of medicine only advances by unpacking what works and what does not work. If we can strip away specific elements that are not contributing to a positive outcome, that saves time, expense, and risk.
– I don’t know what you mean by “move on” in terms of discussing my recommendations with a patient. I don’t fight with my patients. I give them my recommendations and explain them. How far I go with the explanation depends on the patient and the situation. I don’t lie or patronize. I certainly would never recommend a non-scientific treatment just in hopes of getting a placebo effect. I feel that is unethical.

You may notice that I have never commented in this thread on chiropractic or manipulation, so your question is off base. I also get a sense of the shifting goalpost. Are you saying they do work, you don’t care, they only work as a package? It sounds like you want to treat whatever modalities your use as if they work without having to provide evidence for any details of what you do.

But since you ask – I have no problem using common methods of a positive therapeutic interaction, or benign interventions that are intended only for symptomatic benefit. If patients want a massage because it feels good, who cares. I do object to making specific claims about “healing” or improved outcomes if they are not supported by good evidence. That’s deceptive.

Regarding manipulation, the evidence does suggest it is effective for acute uncomplicated back pain. It does not appear to be any more effective than any other standard treatment for back pain, and is usually more expensive. I have no problem with the judicious use of manipulation within evidence-based guidelines.

If all chiropractors did was evidence-based manipulation, I wouldn’t care, and might even refer to them. But that is not all they do. The vast majority incorporate many blatantly pseudoscientific treatments and claims, and something like 30% are energy-based gurus practicing magic. The profession is fatally flawed and needs a major overhaul before I think they should be considered a legitimate part of the medical profession. It’s really up to them. It is chiropractors who have chosen to be hostile to the medical profession and to remain separate. We easily accepted osteopaths once they decided to be science-based and adhere to a standard of care.

StevenNovella: It sounds like we agree more than not. “I have no problem using common methods of a positive therapeutic interaction, or benign interventions that are intended only for symptomatic benefit.” This is what we are talking about, symptom relief.

What seems to me to be the objection from you and others is that chiropractors say things that aren’t scientifically sound and get into treatment of diseases and claim that the spine is the center of all health. I agree that this is objectionable. But not referring a patient for chiropractic because you fear what the chiropractor will say or teach is a bit dodgy.

I do not think we need to unpack what elements of a chiropractic intervention work as long as what they do includes the generally accepted methods of treating back pain. If chiropractors use the commonly accepted treatments of low back pain, that is fine. Manipulation works, ice and heat works, massage works, pleasant conversation works. When they get beyond that into the costly up-selling stuff, we should call them on it. Same as when medical doctors get into up-selling stuff.

I agree that a doc interaction with a patient is individualized. If you think the patient is amenable to education and suggestion, then do it. If you think that it wouldn’t make a difference or see that the patient is convinced of what they want to do, then don’t waste your time. Move on to the next patient.

“When they get beyond that into the costly up-selling stuff, we should call them on it.”

How do you plan on doing this as a GP? Do you ask your patient to visit you after each Chiro visit so that you can assess whether they have been fed claptrap? Your model is simply not sustainable in the long run because those people referred to the Chiro will often believe everything he says and will not be able to sort out the woo from the one genuine treatment they have. What would the conversation sound like “Now, I am referring you for chiropractic, go in there, get your back done, but don’t believe all that other crap he tells you”?

Why not refer the patient to a physical therapist instead? Why give Chiros the business so that they can fund their woo?

Bruce: No, I wouldn’t ask for reports of what the chiropractor told them. Same as I wouldn’t ask them for a list of what they are reading and try to correct that.

Some people here seem to think that the chiropractor is so persuasive and the patient “will often believe everything he says.” What makes you think that is true and why do you think so? Maybe you want to protect them from exposure to that information? I would think that the family doctor should have provided enough education to let the patient make choices.

The family doc can refer to either PT or chiropractic or even do some stuff himself in the office.

Regarding up-selling, one way that could be influenced is through insurance reimbursement. Same as if a surgeon wants to do a procedure in a facility that he owns. Or a pain doctor wants to dispense medication in his office or wants to do multiple spine injections when there is little indication for them. All this is expensive, and it’s all ethically sketchy.

You could have just stopped right there and saved yourself the effort. The minute you believe there is a dichotomy between “science guys” and other people, the minute you show you don’t really know what you’re talking about. Using it effectively as an epithet just shows ignorance, not to mention it’s probably more accurate to refer to us as ‘evidence based guys’.

@zorrobandito “This personal bias probably colors my comments, but it might be useful for you gentlemen to hear from a patient on these topics.”

> But not referring a patient for chiropractic because you fear what the chiropractor will say or teach is a bit dodgy.

Just by reading this thread shortly I am shocked by how much you can misrepresent Steve’s position. I’m not sure you carefully read the post that you are responding to.

The point is that, as a medical professional, it is up to you to provide patients with best possible (science-based) care. That is why you refer them to PT and not to a chiropractor.

Referring them to a chiropractor is not only wrong because it is less or no efficient compared to physiotherapy (and likely dangerous) but also it gives credence and approval to an unscientific approach to medicine, which has a number of negative consequences in itself.

> The family doc can refer to either PT or chiropractic or even do some stuff himself in the office.

And he/she will be making a mistake if they refer to a chiropractic. But I’m glad that at least you stated your position clearly that you cannot back away from it further down the line.

MrQwerty: The chiropractic experience including heat/cold, manipulation, massage, etc., as I have said many times, helps patients by helping to relieve their low back pain. Physical therapy which also uses heat/cold, manipulation, massage, etc., does the same. Osteopaths I believe do the same.

The doc can refer patients to either or neither, and patients can choose which type of provider they want to go to.

There is no evidence whatsoever that chiropractic is “dangerous” in the treatment of low back pain. None. And often it is as efficient as physiotherapy.

You make some of the same points as others have made, that it is somehow “wrong” to refer patients to chiropractors because doing so gives credence to their approach to medicine or that it’s important to protect patients from the propaganda that some chiropractors communicate or that it props up their industry. You’re entitled to that position, but it has no relevance to whether chiropractors do a good job treating back pain.

As for anecdote, the story about the patient who neglected a cancer for a chiropractor and then died is equally anecdotal.

Pain relief is a good thing however it comes about, so long as there are no serious adverse consequences. Pain relief comes about when the patient says it does, since there are no objective ways to measure it.

Even if “the truth” is ignored, and the agency of pain relief was voodoo, or by killing of a chicken or something. I thought the days when people were supposed to suffer for The Truth in the abstract ended with the end of the persecutions of Christians by the Empire.

> The chiropractic experience including heat/cold, manipulation, massage, etc., as I have said many times, helps patients by helping to relieve their low back pain. Physical therapy which also uses heat/cold, manipulation, massage, etc., does the same. Osteopaths I believe do the same.

Saying it many times doesn’t make it any more true.

Studies have found chiropractic treatments to be ineffective except possibly maybe for certain cases of lower back pain treatments, in which cases the treatment is no different from standard physiotherapy.

The trouble is this help, in case of chiropractic, often comes in package with a lot of bogus and potentially harmful nonsense, while same and more help is available in up to date, safer, regulated and science-based physiotherapy.

On the topic of safety, yes there is evidence of danger, going from mild adverse effects to rare serious injuries and possible deaths.

MrQwerty: We are talking about back pain, remember? And I think you probably mean manipulative therapy rather than “chiropractic treatments” anyway So if chiropractic and physiotherapy are “no different,” then it doesn’t matter which one the doc or patient picks, right?

Again, some of you guys object to the “package” because you fear that the patient will be unable to evaluate the information he is given. Better to be shield them from that information, huh? I disagree.

There is zero evidence of “danger” of chiropractic in the treatment of low back pain. Zero. It’s silly to talk about “mild adverse effects;” this can be anything at all. “Possible deaths?” Why would you even bring this up as if it’s a fact? Are there deaths associated with the chiropractic treatment of low back pain?

I think you’re mischaracterizing the opposition to chiropractic a bit.

I object to chiropractic on scientific terms. The mechanisms they claim range form nonsense to vague. So if it’s about as effective as physiotherapy, why go with the bullshit one? Why not go with the one NOT making fantastic claims abut energy and vitalism?

I think we should try to rid ourselves of pseudoscience as much as possible. I think that’s reasonable.

Even if they are roughly equal, which stands a better chance of improving: the one with all the crazy BS mechanisms that isn’t using the scientific method, or the one that has recognized mechanisms and is open to the scientific method?

Steve12: They use the same “recognized mechanisms”: heat/cold, massage, manipulation, etc. That is the point. If you want to squeeze out the chiropractors by limiting their income, that’s your business. But if you want effective care for your low back pain, choose either one.

“Steve12: They use the same “recognized mechanisms”: heat/cold, massage, manipulation, etc. ”

Yeah, there’s overlap in mechanisms, but you don’ even know what they do beyond those things. I asked you many questions about mechanism above, and you relented and couldn’t answer. Which is fine until you start defending those mechanisms tat you told me you don’t understand! Do you believe in vitalism and mystery energy emanating from the spine? Because they do.

And if they both use the same mechanisms, why not go with the one that’s amenable to science?

“If you want to squeeze out the chiropractors by limiting their income, that’s your business.”

Really?

You’re not doing a very good job defending your position (if indeed you have one), but this is ridiculous. Chiropractic mechanism are real because, hey, they need jobs too!

Steve12: If you cannot read what I just said, that chiropractic and PT and others use the SAME “recognized” mechanisms to treat low back pain and that these mechanisms are effective and therefore it makes no difference which provider one uses, then I give up.

If your goal is to only use the providers who are non-chiropractic, that is your right. You will get better no matter which you use, and you will have the satisfaction of doing what you think is correct. Which will probably make you feel better. Good for you.

Others who use chiropractors will get better also and will have the same satisfaction as you do. Ain’t life grand!

@zorrobandito – would you rather your pain appear to go away, spending all kinds of money on something that never seems to really get rid of the pain. DrJoe for example keeps saying that because chiropractors use some methods that legitimate practitioners use, that that makes it ok. Nevermind their often pushers of woo and are generally more interested in bringing you back for more work, over and over.

@DrJoe – “Again, some of you guys object to the “package” because you fear that the patient will be unable to evaluate the information he is given”

You keep missing this point, I believe you’re doing it on purpose. The “package” as it were is often filled with modalities that are next to useless, and only cost a patient money. As YOU yourself have pointed out, they can get the exact pieces that work from professionals other than chiropractors. Dr. Novella explained it very clearly – Science (don’t be scared) cuts away the chaff and makes processes more efficient, and can sometimes improve on those. There’s no reason to send a patient to someone who continues to include the unnecessary.

But, as is often the case in the comments on this blog, you have an agenda, and you can’t seem to veer from that, even when given a rational and logical argument.

“teve12: If you cannot read what I just said, that chiropractic and PT and others use the SAME “recognized” mechanisms to treat low back pain and that these mechanisms are effective and therefore it makes no difference which provider one uses, then I give up.”

Now we’re going in circles.

A. I already said I’m not interested in the mechanisms that are common to pyhsiotherapy and chiro, just the ones specific to chiro. WE’ve already agrees that they work 12 times. You want to argue in this bizarre netherworld where you can defend chiro with the mechanisms common to physio & chiro while dodging discussion of those specific to chiro.

B. Are you seriously dodging with this “to each his own” business? The discussion is not whether I should be free to go to a chiro or physio or whatever. The discussion is whether MDs should be recommending chiro considering the lack of evidence re: the mechanisms SPECIFIC TO chiro. THAT is the issue you keep avoiding.

If you really need to dodge and obfuscate in an anonymous on line discussion, I mean, what is that? Are you trying to engage in a discussion here or do you simply wanna “be right?”.

Steve12: Oh, now you want to discuss the “ones specific to chiro?” Do you seriously want me to dig out everything that goes on in a chiropractor’s office to figure out which ones might be used on a specific patient with back pain for a specific indication as determined by the chiropractor after examination and which of those have been independently studied as to effectiveness? Not gonna happen.

From the beginning, I have said that it is the chiropractic “experience” that helps the patient feel better. We already know that the standard modalities that are used by almost all practitioners are also used by chiropractors as part of the experience/visit/treatment session. These are the standard modalities that are effective in helping to make the patient feel better, whether they are performed by chiropractors, physiotherapists, osteopaths, massage therapists, or family doctors. Whether some chiropractors use other modalities or not in specific patients for specific indications in addition to the standard ones that are known to work and whether or not these other modalities if used are effective in a particular patient, I can’t say and neither can you.

The discussion has always been: do patients benefit from chiropractic care? Do they feel better? The answer to both questions is yes. And since patients benefit and feel better should physicians then recommend chiropractic as an option? The answer to that also is yes.

It seems to me that physical therapy and chiropractic have some overlap, but physical therapy requires more medical training and has a broader capability. However, this insurance study found that for work-related disability of Lower back pain, physical therapists and physicians had a lower success rate than chiros or no care.http://www.ncbi.nlm.nih.gov/pubmed/21407100
I tried to find some info on cost comparison, but I think that varies a lot depending on what country you’re in? Anyway, I think, as usual, the more medical education behind the service, the costlier – so perhaps chiro is a more economical path for those with certain kinds of problems. I do see that there’s a problem if there aren’t certain requirements of practice when a professional is delivering medical care. What to do? Cheapest option of all is probably homeopathy, since the rate of recovery doesn’t seem to be affected by treatment at all, and there’s certainly no risk of injury. 🙂

Oh man, I know I’m gonna get flogged for this, but: we really should acknowledge that MDs also practice some woo to a certain degree, when we look at prescription drugs. What about SSRIs for “chemical imbalance” for example? What about statins?
We have to consider that MDs may be more likely to prescribe unnecessary drugs or treatments for back pain, including surgery. And they may be less likely to consider all of the many contributing factors that back pain may have. On the other hand, would a chiropractor be aware of complicating medical factors?
I guess there’s that whole question no matter what you do – so patients probably need to avail themselves of all options and be well-informed so they can try to make the best decisions for themselves.

I told you this many times – that I’m not interested in the effects that overlap with physio and don’t dispute them. So what’s left?

“The discussion has always been: do patients benefit from chiropractic care? Do they feel better? The answer to both questions is yes. ”

Ha ha ha! Says you, right?

The problem, DrJoe, is that you’re having the discussion that YOU wanna have and you’re ignoring or dodging the questions put to you that are inconvenient. I’ve asked about the specifics of how chiro works like 10000 times, and you dodge and change the subject.

I’m just thankful you’re here to tell us what the scope of the conversation is allowed to be! Thanks man!

It should be noted that beside that vague minor spinal deformity nonsense you were “explaining” about minor spinal deformities.

It should be noted that beside that vague minor spinal deformity nonsense you were “explaining” earlier, you STILL have not given any explanation about the mechanism underlying chiro that does not…wait for it…overlap with physiotherapy.

(in all fairness, this may not be allowable discussion material per the orders of Dr. Joe)

It should also be noted that you ignored my question asking you why -given 2 therapies of equal effectiveness – you would not choose the one that adheres to the scientific method.

(in all fairness, this may not be allowable discussion material per the orders of Dr. Joe)

Chiropractic is steeped in woo, it began with woo and continues to push woo whenever possible. It’s what happens when you fail to base your practices on science, evidence and all of the other wonderful things real medicine uses to heal.

This is keeping in mind that your major defense so far hinges on ‘treating’ pain, and not on the actual healing of those issues.

“We have to consider that MDs may be more likely to prescribe unnecessary drugs or treatments for back pain, including surgery. And they may be less likely to consider all of the many contributing factors that back pain may have. On the other hand, would a chiropractor be aware of complicating medical factors?”

This is all pretty ridiculous. While it’s possible some doctors may over prescribe, that’s not practicing woo, that’s just not practicing medicine well. You’re other assumptions are just that, assumptions with no real basis in fact.

It you are providing this as an absolute statement, it is incorrect.
The patient might say his pain is less…
– because he wants to please the chiropractor who has tried hard to help him.
– because he does not want to upset the chiropractor who has tried hard to help him.
– because he imagines he feels less pain when he actually doesn’t.
(like the asthmatic patient who feels his asthma is better while objective tests show no improvement)
These are real phenomena whether you like it or not.

“…since there are no objective ways to measure it”

You actually can.
You can measure it against placebo.
If there is no effect above placebo, that treatment did not lessen the pain, regardless of what the patient says (see above).

1. What specific parts of chiropractic therapy for low back pain that do not overlap with physiotherapy do you want to discuss?

2. “It should also be noted that you ignored my question asking you why -given 2 therapies of equal effectiveness – you would not choose the one that adheres to the scientific method.” Answer: because it doesn’t make a difference to the health, recovery, well-being of the patient.

Grabula: “This is keeping in mind that your major defense so far hinges on ‘treating’ pain, and not on the actual healing of those issues.” Treating pain is the issue here. What “actual healing” are you talking about? Relief of symptoms is what it’s all about. That’s what the patient wants when he goes to a provider for help. He wants relief of symptoms.

BillyJoe: You couldn’t be more wrong. (Well, maybe you could.) Pain relief DOES come about when the patient says it does. There is no objective way to measure pain relief other than patient report. Pain is a symptom reported by the patent.

If you are saying that patients “imagine” that there is pain relief when in fact there isn’t, then all the studies measuring the effectiveness of different treatment modalities for relief of symptoms are invalid. All the studies saying that treatment A is more effective than treatment B as judged by patient reports of pain relief are out the window.

Your methods of determining efficacy of a treatment are divorced from medical science.

“Relief of symptoms is what it’s all about.”

Punching a person in the face with lower back pain, while the person may feel temporary subsidence of lower back pain, it does not make punching a person in the face an effective treatment for lower back pain.

The punching in the face treatment meets your criteria of efficacy.

Your criteria for determining efficacy has been weighed, it has been measured, and it has been found wanting. It is…totally inadequate.

Hoss: You are incorrect. Relief of symptoms IS the standard for determining efficacy of modalities meant to relieve those symptoms. If the modality is meant to relieve pain, then the standard for determining whether the modality is effective is whether the pain is relieved. And the only way to determine whether the symptom of pain is relieved is to ask the one with the pain.

Your punch example is not relevant. You are saying that a more painful stimulus will temporarily take precedence over a less painful one. Of course that is true. It’s a (temporary) distracting injury. But it has nothing to do with chiropractic or any other modality for treatment of back pain, none of which relies on inflicting pain to distract the patient.

JoeinCA
“You are incorrect. Relief of symptoms IS the standard for determining efficacy of modalities meant to relieve those symptoms. If the modality is meant to relieve pain, then the standard for determining whether the modality is effective is whether the pain is relieved. And the only way to determine whether the symptom of pain is relieved is to ask the one with the pain.”

I gave you an example demonstrating that your criteria for determining efficacy is inadequate. The punching in the face treatment could have just as easily have been tickling, watching a movie, or sugar pills(all of which fulfill your criteria for efficacy as long as there is a perceived relief in symptoms).

“But it has nothing to do with chiropractic or any other modality for treatment of back pain, none of which relies on inflicting pain to distract the patient.”

I’m addressing standards of efficacy not the efficacy of chiropractic.

Steve12: This is hard to believe. I told you that the stuff that chiropractors do includes the common treatment modalities for low back pain. You claim there is something else that they do, and this is one of your objections to chiropractic. I ask you, what is that something else? I don’t know what it is or whether there even is something. Maybe there is something else that they do. Maybe not. Do you know? I don’t.

You are the one with the strong negative opinion about chiropractic based on their teaching and, I gather, based on the fact that you think something else goes on behind those closed doors that is ineffective or harmful. I’m asking you what you think that is. I don’t know if ANYTHING goes on behind those closed doors that is ineffective or harmful. Do you?

JoeinCA
“I told you that the stuff that chiropractors do includes the common treatment modalities for low back pain. You claim there is something else that they do, and this is one of your objections to chiropractic. I ask you, what is that something else? I don’t know what it is or whether there even is something. Maybe there is something else that they do. Maybe not. Do you know? I don’t.” on 13 Mar 2014 at 3:13 pm

“My understanding of “manipulation” is that the chiropractor feels there are minor deformities in the spinal joints that they “adjust.” I have no idea how many patients with low back pain who see chiropractors have these deformities or how much pain this causes or how many benefit from manipulation. If there is a minor subluxation and that is causing pain, adjustment would help that. But again, who knows how many patients have this?” on 11 Mar 2014 at 12:32 am

JoeinCA
“If you have criteria for efficacy other than patient report of pain, what are they?”

Large placebo controlled double blind clinical trials seem to be pretty good at mitigating bias and self-deception for determining efficacy. Controlling variables, as I understand, can be pretty tricky though.

Mlema:“We have to consider that MDs may be more likely to prescribe unnecessary drugs or treatments for back pain, including surgery. And they may be less likely to consider all of the many contributing factors that back pain may have. On the other hand, would a chiropractor be aware of complicating medical factors?”

grabula: “This is all pretty ridiculous. While it’s possible some doctors may over prescribe, that’s not practicing woo, that’s just not practicing medicine well. You’re other assumptions are just that, assumptions with no real basis in fact.”

I’m talking about prescribing drugs that don’t treat the supposed problem and also cause harm. It’s more the fault of the pharmaceutical industry, but the doctors are the ones prescribing them. Likewise, spinal fusion for certain back problems makes a permanent level of disability where there is apparently an otherwise better resolution and return to work.

I’m saying that when it comes to treating back pain, neither chiros nor MDs, or physical therapists have a solution that’s any better than no treatment as far as recurrence.

Chiros may proffer woo, but MDs are offering some of the same woo, plus more permanent injury in some cases because of the more aggressive intervention. NOT ALL DOCS. I personally know docs that advise no intervention at all in some cases of pain (ex shoulder repetitive movement injury) where others want to do injections or surgery. I’ve seen pain resolve, often with nothing more than consciousness of what may be causing the injury. This could be anything from stress to posture to repetitive motion.

“BillyJoe: You couldn’t be more wrong. (Well, maybe you could.) Pain relief DOES come about when the patient says it does. There is no objective way to measure pain relief other than patient report. Pain is a symptom reported by the patent”

You have not addressed any of my points.
You are happy to simply proclaim that I am wrong and that you right.
What a fine line of argument you have going there.

If a treatment offers no pain relief better than placebo, then there is no pain relief due to that treatment no matter what the patient says.

And I suppose those asthmatic patients who said they felt better really were better and can now go out without their inhalers and ignore those pesky objective tests that show they were no better at all.

BillyJoe: “You actually can. You can measure it against placebo. If there is no effect above placebo, that treatment did not lessen the pain, regardless of what the patient says (see above).” This in answer to Zorro’s claim that you cannot measure pain relief.

Then you go on to say that there are other reasons (pleasing the provider, “imagining that the pain was gone(!)”) why patients might say that their pain is reduced other than the fact that it actually was reduced.

So then, according to you, patients’ report of pain relief is unreliable because you don’t know whether they are lying to you or not. Is that not true?

As I said, how then could you evaluate any report of treatment efficacy if the report is based on what potentially is a lie? Why should the incidence of false patient reporting be any different from chiropractic to physical therapy?

All the studies of efficacy are based on patient reporting of relief of symptoms. If you cannot believe the patient reporting, how can you believe the studies?

You are comparing this with the treatment of asthma? Wrong again. There are objective tests to determine the severity of asthma, and treatment modalities are measured by their effect on those objective tests. This is unlike the results of treatment of pain which relies on the patient to say benefit or no benefit.

Hoss: Really? When I say that many treaters of back pain use manipulation and I speculate on why that works, that’s intellectually dishonest? When I say that I don’t know how many patients benefit from this manipulation treatment, whoever does it, that’s intellectually dishonest? When I ask the chiropractic doubters to specify exactly what there is about chiropractic treatment that they dislike/find offensive and they cannot, I am being the intellectually dishonest one?

When the alleged “scientists” on this blog discount the patient report of relief of pain because there must be some reason for that report other than that it actually occurred, I am being intellectually dishonest? When I ask for other methods of determining efficacy than patient reports which are not to be trusted and I get no other methods, I’m being intellectually dishonest?

BillyJoe, thanks for the “lesson” but I don’t get it. What am I saying is logically fallacious? I’m not arguing any position, except possibly the one that says patients should learn as much as they can about all their options, including what results and cost they might expect.

Hoss: If you have criteria for efficacy other than patient report of pain before and after, what are they?

If you do not trust the patient’s report of pain relief to be accurate, how do you judge success?

If you, like BillyJoe, say that it is “incorrect” to say that “pain relief comes about when the patient says it does,” then how would you ever do a study?

If you study a modality and ask the patient whether they got pain relief following the modality and don’t believe that they really really got pain relief, then why do the study?

Better yet, if you see a patient who has gone to a chiropractor only and comes back reporting pain relief, do you believe the patient (a) got pain relief, (b) got pain relief from the chiropractic experience, (c) got no pain relief, or (d) got pain relief from something other than the only treatment they had which was chiropractic care?

“So then, according to you, patients’ report of pain relief is unreliable because you don’t know whether they are lying to you or not. Is that not true?”

Lying is a bit strong.
They may not be just trying to please the chiropractor who’s gone to so much trouble.
They may be truly convinced that their pain IS improved.

“All the studies of efficacy are based on patient reporting of relief of symptoms. If you cannot believe the patient reporting, how can you believe the studies?”

Because they are placebo controlled studies.
Let me repeat…
If a treatment offers no pain relief better than placebo, then there is no pain relief due to that treatment no matter what any particular patient says.

“You are comparing this with the treatment of asthma? Wrong again. There are objective tests to determine the severity of asthma…”

You missed the point completely:
If patients can be wrong when they say that their asthma is better, then they can be wrong when they say their pain is better.

“…This is unlike the results of treatment of pain which relies on the patient to say benefit or no benefit”

Let me repeat again…
If a treatment offers no pain relief better than placebo, then there is no pain relief due to that treatment no matter what any particular patient says.
In other words, a placebo controlled trial can distinguish between real pain relief and imagined or reported pain relief.

Drjoe
“If you have criteria for efficacy other than patient report of pain before and after, what are they?”
Demonstrating efficacy, I’m ok with any method or set of methods that minimizes bias and error(placebo, double blind, ect…).

“If you do not trust the patient’s report of pain relief to be accurate, how do you judge success?”
A patient might be telling the truth, but to judge success, I would think that going by what the patient said would be reasonable if the treatment has previously been proven to be effective. Of course this question has nothing to do with efficacy.

“If you, like BillyJoe, say that it is “incorrect” to say that “pain relief comes about when the patient says it does,” then how would you ever do a study?”
Magic
Seriously though, using methods to minimize false positives does not make it impossible to do a study.

“If you study a modality and ask the patient whether they got pain relief following the modality and don’t believe that they really really got pain relief, then why do the study?”
Studies need proper controls that minimize false positives. You appear to be arguing against placebo control, which has the effect of increasing false positives.

“Better yet, if you see a patient who has gone to a chiropractor only and comes back reporting pain relief, do you believe the patient (a) got pain relief, (b) got pain relief from the chiropractic experience, (c) got no pain relief, or (d) got pain relief from something other than the only treatment they had which was chiropractic care?”

(E) the person(not patient, because chiropractors aren’t doctors) probably experienced a relief in pain due to several possible factors, one of which includes the chiropractic experience. This alone is not a demonstration of efficacy. This question is only bias in that it is only examining positive data. You’re ignoring people who get worse back problems, people who don’t experience any relief at all, and the placebo control group comparison.

Hoss:
“A patient might be telling the truth, but to judge success, I would think that going by what the patient said would be reasonable if the treatment has previously been proven to be effective. Of course this question has nothing to do with efficacy.” You are going around in circles. The only way for a treatment to be proven effective or not effective is by patient report. That is the criterion.

“Studies need proper controls that minimize false positives. You appear to be arguing against placebo control, which has the effect of increasing false positives.” But again, if you don’t trust what the patient says….

Of course, chiropractors are doctors. Come on now.

BillyJoe: “If patients can be wrong when they say that their asthma is better, then they can be wrong when they say their pain is better.” There is no “wrong” when a patient says their pain is better. There is telling the truth or not telling the truth. The patient is the only judge of whether his pain is better.

Are you presuming that if the patient says they are better and you believe they are not really better that you would continue to treat that patient? To what end? When would you stop treatment of a patient who says he is better?

“a placebo controlled trial can distinguish between real pain relief and imagined or reported pain relief.” That is not true at all. The pain relief is real; the only question is the cause.

And of course, just to keep you on track here, there is no evidence at all that chiropractic which uses all the modalities that other back pain treaters use is a placebo. And remember way back when that the original question was whether the chiropractic experience works.

“In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.”

Maybe one way to evaluate efficacy that BillyJoe and Hoss would approve of is to compare it to that of a treatment provider of whom they also approve?

Pain isn’t asthma. There is no objective test for it.
If I say it hurts, it hurts. If I say it doesn’t hurt, it doesn’t hurt. Sorry doctor.

Someone can say it hurts when it doesn’t. Some people I know can have their teeth drilled and filled without anesthesia. Amputees can have phantom pain in their amputated limb. We all get more or less used to chronic symptoms, and we all can more or less ignore pain for a worthy cause.

If a chiropractor, a shaman or a priest manage to relieve pain, it’s good for the sufferer. That does not mean that the reasons these people advance for their success are valid, or that they treat the cause of the pain if the cause is not in the brain (like phantom limb pain).

The theory behind chiropractic (and shamanism, faith-healing and homeopathy) remains nonsense no matter how many people are helped by spinal manipulation, prayer, or distilled water, so why not see what causes the pain relief, and apply it without the mumbo-jumbo?

It’s starting to seem weird that we have these different professions, but it kinda seems like people choosing to be chiropractors nowadays don’t really believe the theory behind it. It’s just another healthcare profession where they might be able to make good money, and it’s not as demanding as MD or DO. Perhaps they’re also more likely to have their own business than a PT, and make more money. Perhaps that motivation leads to some of the unscrupulous practices that they seem to have a reputation for doing. There’s quite a bit of schooling required, along with board exams and licensure. What I seem to gather from online anecdotes is: never forgo medical exam for chiropractic exam, and use Angie’s list or something if you decide to use a chiropractor.

Is there also no “wrong” when patients say their asthma is better.
If yes, what about those objective tests that indicate that these patients’ are not better.
If no, why is pain different?

“There is telling the truth or not telling the truth”

Now you are arguing against your own point:
There is telling the truth when a patient says their asthma is better.
And there is not telling the truth when a patient says their asthma is better.
Or do you think patients are incapable of telling lies?
Do you think patients are incapable of saying their pain is better (for whatever reason) when, by their own evaluation, they don’t actually feel that their pain is better?

“The patient is the only judge of whether his pain is better”

Let’s accept that for the moment.
Take the patient who judges that his pain is not better. Do you think that patient is incapable of saying that it IS better? Do you think there are no reasons that would cause a patient to say his pain is better when, by his own judgement it is not better?

“Are you presuming that if the patient says they are better and you believe they are not really better that you would continue to treat that patient?”

Why would I continue to treat a patient who says his pain is better? Because he might want to get rid of his pain altogether. Would I continue to treat his pain when he says it has resolved altogether? Why on Earth would I do that? If he says that his pain is gone when he actually still feels pain, it may be because he has decided I can’t help him and that he has decided to go elsewhere or seek other types of treatments but, at the same time, he doesn’t want to hurt my feelings by telling me my treatment was useless.

“When would you stop treatment of a patient who says he is better?”

When he says that his pain is no longer improving with the treatment, or when he says that his pain has resolved completely. Of course i would be using treatment for which there is evidence of effectiveness beyond placebo.

“The pain relief is real”

You are wanting me to believe that…
– not a single patient can be deceived into thinking his pain is better.
– not a single patient can deceive himself into thinking his pain is better.
– not a single patient can believe his pain is no better but say that it iS better.
– not a sinlge patient wants to please his practitioner by saying his pain is better.
– not a single patient wants to avoid upsetting the pratitioner by saying his pain is no better.
You are asking too much.
And you are expecting too much of your patients.

No they aren’t. or at least only in the academic sense. they are certainly not physicians. a doctorate in chiropractic ( incidentally chiropractic what? even the grammar is wrong) is similar to a doctorate in divinity. sure they studied for it but their appearance in a sickroom is worrying.

“There is no “wrong” when a patient says their pain is better”

yes there is. and i know this from the front end. a patient with incurable chronic pain will wish to be better, to have a cure. they can be defrauded of a lot of money by people who prey on others by selling false hope, such as homeopaths and to some extent chiropractors ( except for the physio parts but physio is a lot cheaper). But the truth is that the psychological modification of pain is well known. pain management clinics can teach how to maximise this without ever lying to the patient or defrauding them or trying to get them to believe they are cured.
Importantly the giving of false hope where none exists is corrosive. it would land you in Dantes hell for a start. It is fundamentally wrong.

Drjoe
“The only way for a treatment to be proven effective or not effective is by patient report. That is the criterion.”
Person goes to see a faith healer.
Faith healer does their magic.
Person reports feeling better.
Faith healing is thus proven efficacious.

This scenario completely fits how you would determine efficacy. Your criteria for demonstrating efficacy is inadequate as shown with the faith healer example(among others that have already been given). Your method by itself is a joke. Most studies done by people who advocate for chiro are horribly designed. Gotta make sure we have low testing standards so we can confirm anything we want. It’s a joke.http://www.sciencebasedmedicine.org/top-10-chiropractic-studies-of-2013/

“and to some extent chiropractors ( except for the physio parts but physio is a lot cheaper)”

I wanted to ask this. There may be no general answer.

On average, is PT cheaper or are chiropractors cheaper? I am not subject to lower back pain and I know almost nothing about chiropractors (except what I learned here), but it seems to me that this is an important question. If (ignoring for just a moment, if you will, everyone’s overwhelming anxieties about “woo”) chiropractor and PT would be about equally effective for back pain, wouldn’t cost be a factor?

I would think the net cost to the patient is the number we’re looking for. I am getting physical therapy for a recently replaced knee, and this is covered by my insurance. No one I know of recommends a chiropractor for recovery from a knee replacement, so the question doesn’t arise in my case.

Do the services of a chiropractor tend to be covered by insurance, or not? And how hard is it to get physical therapy covered? I know that not long ago I fell off a horse, and my GP immediately wrote a prescription for physical therapy for my injured shoulder, which would bring some of the cost at least under insurance. (I ended up not using it and the shoulder got well by itself.)

My horse trainer (a spectacularly gifted rider of about 44) swears by his chiropractor (there is a massage therapist in the same building, so he makes a morning of it when he goes there). Horseback riding is hard on joints and backs and on bodies generally if you do as much of it as he does.

(If you tell this guy that he’s not getting pain relief when he thinks he is, he might punch you in the face, being a cowboy of the old school.)

Hoss: Look at all the studies. The criterion for whether a treatment modality works for pain relief is patient report. You speak of faith healing as if you have never heard of the placebo effect. Talk to BillyJoe about that.

Yes, chiropractors are doctors with licenses and boards and education and all that doctor stuff.

Incitatus: Of course, a patient will wish to be better. The question is, why would you not believe a patient when they say they ARE better? What is their self-interest in reporting no pain when they are actually in pain? How is that a psychological advantage to state they are better when they are not?

BillyJoe: You are correct that a patient may lie and say his pain is better in order to get away from your treatment which has not worked. In that case, however, he will go somewhere else for continued treatment. But when a patient does in fact believe that his pain is gone and he wants or needs no further treatment, you have no basis for saying that he does have pain. Claiming that one still has pain and wanting more treatment, drugs, etc., when one doesn’t have pain is lying for personal gain. What is the personal advantage to a patient to state that his pain is gone when it is still there?

There’s just no advantage to a patient who is in pain to lie in order to stop treatment, unless of course the pain is insignificant (better than it was) or the treatment is worse than the pain or they’re bored with the whole process and just want to move on because what pain there is is just not a problem any more (better than it was). Pain relief is almost never total relief from whatever treatment the patient undergoes, and often there is lingering but insignificant pain that is tolerable and that doesn’t interfere with the patient’s life. That’s often the goal of treatment, to help the patient to gain functional improvement.

Stop with the asthma. There is nothing at all similar between asthma and low back pain.

“The question is, why would you not believe a patient when they say they ARE better?”

This is kind of a good question.

Because……even though you represent yourself as a healer, you want the patient to be worse off than they say they are? That’s crazy. They experience pain relief but you want to talk them out of it? Why would anyone want to do that? Mostly doctors (who are justifiably anxious about overuse of opiates) try to talk you into the idea that you are NOT in pain when you say you are. Why reverse course?

I’m right now recovering from surgery. It’s going well, but I’m in pain off and on. When I have a good day I’m not very receptive to some physician who tries to talk me into the idea that I’m really in pain, even if I’m only having a good day because the weather is nice. Or because someone did voodoo in my living room.

Pain relief is pain relief, you guys. All pain relief is a mixed bag, most definitely including opiates. It’s a balancing act. If a voodoo rite in the living room will work, well, bring it on, it has fewer adverse side effects than most.

JoeinCA
“Look at all the studies. The criterion for whether a treatment modality works for pain relief is patient report. You speak of faith healing as if you have never heard of the placebo effect. Talk to BillyJoe about that.”

Holy crap. Do you really not understand that I was giving an example that meets your criteria of efficacy? The error that you pointed out with my faith healing example is the exact same error you’re making talking about chiropractic.

But I’m glad you agree that patient report alone isn’t enough to determine efficacy. Now you just need to apply it to the claims your making.

“You seem to have trouble with the definition of “work.” They feel better following their treatment by a [faith healer]. Whether it is because [methods of faith healing] that they get with visiting one provider. Having no pain after treatment = feeling better after treatment = hmmm, maybe what just happened to me helped my back pain.” on 08 Mar 2014 at 2:38 pm

See what I did there. What you’re advocating for is unable to distinguish between effective and non-effective treatments. You’re using different criteria than patient reporting alone to discount the faith healing and punch-in-the-face treatment examples I gave you, which has to be done to determine efficacy.

Its almost as if you’re purposefully misunderstanding what I’m saying.

“Its almost as if you’re purposefully misunderstanding what I’m saying.”

Exactly. Dr Joe is one of these people who can’t even be wrong about little points. So he has to purposefully obfuscate and dodge to preserve being “right”. I don’t believe that anyone who can make it through med school can’t understand simple English It’s all a game in defense of DrJoe’s ego, which is silly. It’s an anonymous discussion, for chrissakes…

What’s so awful about taking apart the different components leading to pain reduction among these modalities? We can’t even talk about those components because of this “Wh’s on First?” routine he’s running here.

I mean, if you go through the above, he’s pretending that he doesn’t understand what it means to separate the components. It’s quite odd, actually.

Dr Joe now agrees that patients can lie, can be deceived, and can deceive themselves.
In other words he effectively admits that when patients say they are better they may not be better.
But he continues to say that when a patient says his pain is better then it is better.
And he continues to reject the asthma example that demonstrates that patients can say they feel better when they are objectively not better.
And he continues to reject the fact that placebo controlled trials also demonstrate that patients can say they feel better when treatment they were given has been shown to be ineffective.

BillyJoe: Wow. Patients can lie (a) when they don’t feel better but want to get away from your ineffective treatment to pursue other treatment. (b) When they feel better but want to continue or escalate treatment for personal gain.

“But when a patient does in fact believe that his pain is gone and he wants or needs no further treatment, you have no basis for saying that he does have pain.”

You continue to believe there are instances where the patient has “deceived themselves” into thinking that his pain is better. That’s ridiculous. And it’s also ridiculous that you think I actually said that.

“There’s just no advantage to a patient who is in pain to lie in order to stop treatment, unless of course the pain is insignificant (better than it was) or the treatment is worse than the pain or they’re bored with the whole process and just want to move on because what pain there is is just not a problem any more (better than it was).”

Worse, you continue to bring up the asthma example when it has no bearing at all upon this discussion of the treatment of a symptom of low back pain. The relevant difference of course is that there are no objective signs in low back pain, there is only the patient report. Big difference. So when a patient tells you that their back pain is better, that is the end of it. No more treatment. When an asthma patient tells you that they feel better, it is not self-deception, but in fact they might feel better. One would still wait until the numbers verify the fact that their improvement is lasting and not transient. See the difference?

Steve12: You continue to fail to tell me which individual components of chiropractic you would like to discuss. Really, name something. Maybe we agree.

Hoss: Including “faith healing” into the discussion is meaningless. What makes the patient feel better after chiropractic treatment is all the modalities that many practitioners use such as heat/cold, massage, manipulation, etc. Same thing they get at the physical therapist or osteopath. Perhaps if Steve12 ever stops grousing, he will share some other modalities that chiropractors use that are less effective. But for now, let’s go with chiropractic is effective because chiropractors do what is the generally accepted treatment for low back pain.

So, so, so ODD. Just weird to pretend you don’t understand a simple question.

“Steve12: You continue to fail to tell me which individual components of chiropractic you would like to discuss. Really, name something. Maybe we agree.”

I asked for all of the components that do not occur in physiotherapy. Why can’t you understand that?

How’s this? Let’s replace ALL with ANY!

Explain the mechanism of ANY component of chiro that isn’t also present in physiotherapy.

any – *you choose!*. Wildcard baby. Can’t avoid this one, right? I mean, how much more can you embarass yourself with this “But I don’t understand the question!” nonsense? I guess we’re gonna find out…

“You continue to believe there are instances where the patient has “deceived themselves” into thinking that his pain is better. That’s ridiculous”

So it seems you accept that a patient can deceive themselves into thinking that their asthma is better, but you reject the possibility that a patient can deceive themselves into thinking that their pain is better.
Really, who’s looking ridiculous here?

But I see you have no argument against the placebo controlled trials that demonstrate that certain treatments are ineffective in relieving pain whilst, at the same time, showing that patients using these ineffective treatments, say their pain is better.

Steve12: How about, I don’t know what components chiropractors use other than the ones I listed. I don’t know if there are any, and, if there are, what they are. You are convinced there are others, so you tell me what they are and we can discuss. Why is that so hard?

BillyJoe: This is what I said. “When an asthma patient tells you that they feel better, it is not self-deception, but in fact they might feel better. One would still wait until the numbers verify the fact that their improvement is lasting and not transient.” So where do you get that I “accept that a patient can deceive themselves into thinking their asthma is better”? You need to read more carefully. Oh, and again you should not use asthma as an example of patient “self-deception” because it is not.

When did I “argue against” trials demonstrating that certain treatments are ineffective?

“When an asthma patient tells you that they feel better, it is not self-deception, but in fact they might feel better. One would still wait until the numbers verify the fact that their improvement is lasting and not transient”

You have misunderstood the trial.
The patients say that their asthma has improved. At the same time, the objective measurements indicate that their asthma has not improved. They have deceived themselves into believing that their asthma has improved.

BillyJoe: I keep asking you to drop the asthma analogy because it is not relevant. Patients who have asthma attacks and at some point “feel better” are not “deceiving themselves.” They actually do feel better. They actually are breathing better. This is a subjective feeling that has occurred due to treatment, not “self-deception.”

That’s like saying that a patient with a broken bone who gets treatment for pain and then has less pain is “deceiving himself” into thinking he is better, while in fact his bone is still broken.

No relevance to low back pain at all which does not have objective measurement criteria. Really.

JoeinCA
I’m not sure what’s so hard to understand. My core argument has nothing to do with lower back pain or chiro.
Patient has symptoms.
Patient uses a treatment that can’t work.(maybe something like a perpetual motion photon collider that’s claimed to reduce symptoms…or whatever other treatment that doesn’t work)
Patient reports a decrease in symptoms. (See how Billyjoe’s asma example is relivent)
You apparently don’t care the treatment is ineffective as long as the patient has, what they believe to be, symptom relief.
I care whether the treatment was actually effective, and if a treatment has an effect similar to placebo, then the treatment does not work.
Your BS hand waving does not make a treatment with effects similar to placebo, even with some patients reporting a reduction in symptoms, effective.

I think people keep bringing up asthma because there is an objective test for it, and the people doing this are very fond of objective tests, as aren’t we all.

However, pain cannot be tested in this fashion, so the analogy, as Joe keeps point out, is not a helpful one. The treatment of pain, a difficult field at best, might be easier if there were such a test.

In the absence of objective data doctors pretty much have to take the patient’s word for it. Doctors hate taking the patient’s word for anything. That’s why asthma, which is completely irrelevant to the discussion of lower back pain, keeps coming up: they can test for asthma, so they’d rather talk about that.

Zorrobandito
You need to reread what other commenters have written about asthma. You’ve misunderstood what the point of that line of reasoning was for.

Test subjects(I’m going to start referring to people having medical testing done to them as test subjects and not patients from now on) can and do report symptom relief when taking a placebo. The distinction you’re attempting to make between objectively verifying and subjectively verifying symptom relief is not relivant as the placebo effect is prevelant in both. Both the asthma example and my punch-in-the-face hypothetical are attacking the same fallacy being made.

Hoss: And you are wrong on both the punch-in-the-face and the asthma examples as I have already pointed out several times.

First of all, the punch-in-the-face does not “relieve” pain; it provides a distracting pain. This analogy has nothing at all to do with treatment of symptoms.

Second, well, we’ve already dispensed with asthma several times.

Third, your reference to patients using “a treatment that can’t work” has nothing at all to do with the use of chiropractic, which is what the discussion is all about. Unless you are claiming that chiropractic is “a treatment that can’t work.” Are you?

Finally, the ONLY criterion of whether a treatment works or not is patient reporting. We know that placebos work and we know that chiropractic that uses the standard treatments for low back pain works and we know that photon colliders don’t work. And we know all this because of analysis of patient responses to treatment. Not only test subjects, but patients.

“I think people keep bringing up asthma because there is an objective test for it”

This is incorrect.

We bring up this example because it demonstrates that when patients say they are better, they may not actually be better.
Therefore you cannot rely on what patients say in deciding whether a treatment works.
This directly contradicts what both you and DrJoe are claiming.

Sure, the example is about patients saying that their asthma is better.
But, if asthmatic patients can report that their asthma is better when it can be objectively demonstrated that it is not better, then why can’t pain patients report that their pain is better when it is not better?
That’s the first point we are making.

The second point we are making is that patients report their pain is better using treatments that have been shown by placebo controlled trials to not work.
In other words, patients say their pain is better using treatments that do not help to reduce pain.
They are saying their pain is better when it is not better.
This contradicts what both you and DrJoe are claiming.
Therefore you cannot rely on what patients say in deciding whether a treatment works.

(Please address all my points in your response.
It won’t help your argument to pick one point out of context.
It won’t help your argument to simply repeat it.)

BillyJoe;
1. “But, if asthmatic patients can report that their asthma is better when it can be objectively demonstrated that it is not better, then why can’t pain patients report that their pain is better when it is not better?”

Because what patients report is that their SYMPTOMS of asthma are better, their symptoms of shortness of breath, etc. The objective evidence of asthma being better or worse does not involve a measurement of symptoms but of objective signs. They are two different things. That’s why the patient can report an improvement in symptoms while the objective measurements are going the other way.

Of course, patients could lie about their pain being better to get away from your treatment and move on to another treatment, or to get away from all treatment. But this is a conscious decision, not a self-deception.

2. “In other words, patients say their pain is better using treatments that do not help to reduce pain.
They are saying their pain is better when it is not better.” Don’t you see that this does not follow? What you are saying is that the patient uses a treatment that you think does not help to reduce pain or that has not been shown to reduce pain, and then when he reports pain relief, you are saying that he in fact still has pain. How can you possibly know that he still has pain if he says he doesn’t? Really. Think about it. Where are you getting the information and how are you evaluating that he still has pain?

So if you were his doc and he went to have a photon treatment for pain and came back and said he was pain free, would you continue to treat him for pain that he doesn’t have?

“I keep asking you to drop the asthma analogy because it is not relevant”

You keep asking me to drop it because (together with the second point – see reply to zorrobandito) it destroys your argument.

” Patients who have asthma attacks and at some point “feel better” are not “deceiving themselves.” ”

That trial is not about patients with asthma attacks.
It’s about patients with asthma symptoms.
The trial demonstrates that some patients with asthma symptoms who are given a treatment that does not work say their asthma has improved. They say their asthma has improved after using a treatment that does not work and despite objective tests showing that their asthma has not improved. Therefore, when these asthmatic patients say their asthma has improved, they are wrong. Their asthma has not improved.

“They actually do feel better. They actually are breathing better. This is a subjective feeling that has occurred due to treatment”

The treatment they were given is ineffective.
The objective tests show no improvement.
Therefore, if they say their asthma is better, they are wrong.

“No relevance to low back pain at all which does not have objective measurement criteria”

Please read my response to zorrobandito.
Please address all my points in that post.
It won’t help your argument to pick out one point out of context.
It won’t help your argument to simply repeat it.

Bruce
Perhaps you’re right. I’m fairly confident DrJoeinCA won’t be convince out of his entrenched posistion. While a goal of mine was trying to convince him, it is not my main goal. Personally I don’t feel as if my time has been wasted. I’m trying to learn as much as I can and trying to refine my argueing skills.

I also hope that perhaps even some of the arguments being made will help others.

I know most of the comments now are repeating and are slight variations of arguments already made at the beginning of the comment section, and I felt that others have already decimated DrJoe’s arguments. But I felt compelled to speak…so I did.

BillyJoe: That is the point and the difference between asthma and pain. When you have OBJECTIVE ways of measuring something, an effect of treatment say, then you use those. When you have ONLY SUBJECTIVE means, like patient report of pain relief, then you can only use those.

So when a patient reports pain relief and you have no objective way of measuring pain relief, you go with what the patient says. That’s all you have and you cannot contradict it because it’s subjective. You can’t say that the patient doesn’t have a headache when he says he does. And you for sure can’t say the patient has pain when he says he doesn’t.

When you discharge a patient with asthma, you have clinical measurements to document treatment success. When you discharge a patient who had a headache and now says it’s gone, your measurement of treatment success — whatever the treatment — is the patient report.

“Perhaps you’re right. I’m fairly confident DrJoeinCA won’t be convince out of his entrenched posistion. While a goal of mine was trying to convince him, it is not my main goal. Personally I don’t feel as if my time has been wasted. I’m trying to learn as much as I can and trying to refine my argueing skills.
I also hope that perhaps even some of the arguments being made will help others.”

Yeah, I fully understand that and can see your point. It has been quite a lesson in spotting fallacies (even in my own thinking). For me this discussion is over… as I have said many times before there are some on here who show much more patience than I would ever have.

DrJoe

“Yeah, if you can’t logically make the case in 200 posts, probably time to reconsider one’s position. Or take a nap. Either one.”

The case has been made logically many times over, the fact that you keep shifting the sands and completely not addressing properly what BillyJoe, Steve, Hoss and others prior to them have pointed out is not a failure in my thinking, but I think rather a failure in yours. You will find that the posters on this “forum” are very good at getting to the root of the matter quite quickly, and the fact that so many see flaw in your argument should be a red light to you to really consider your own position.

DrJoeinCA I am afraid i have been away from here for a while and so am late responding:

“The question is, why would you not believe a patient when they say they ARE better? What is their self-interest in reporting no pain when they are actually in pain? How is that a psychological advantage to state they are better when they are not?”

No that is not implied in what i said really. Or it was not my intention. If the chiropractors are aiming at the symptomatic relief of pain then there are fewer ethical quibbles, because psychological approaches of the type they offer do relieve pain ( not nociception, pain) at least temporarily. However the mode by which they do so is fundamentally costly as it is therapist led- to get the effect you go to the therapist and he pretends to treat you. Which costs money. Most pain management clinics will teach the patinet ohow to employ psychological pain management themselves, which is much much more cost effective and as effective long term in pain treatment. Given that the effect is purely perceptive in fact anyone can administer it. Given what chiropractors tend to charge near me it would be much more cost effective to hire a hooker to give you a massage than to get one from a chiropractor and the therapeutic effect would be just as great. There may be legal issues there, depending on local laws.

But that’s assuming that the chiropractor accepts that what they are doing is offering symptomatic relief via sleight of hand. If it is sold as such, then as i say its mainly a cost quibble for me. However it is rare in my experience to find a chiropractor who claims just that. they normally claim to be able to cure (whatever). I have had one or two offer to cure me. Given that i have a disorder they have probably never heard of, and i would bet would be unable to spell, which is genetic autosomal dominant good luck with that one. But they are confident they can cure it. Because magic.

Thats when i have the difficulty, because those people are vultures preying on the hopeless.

You make a big thing about objecting to the use of reported pain. However as any chronic pain patient would tell you pain scores and pain diaries are generally used in treatment. ( if you have chronic pain and they aren’t, then slap your GP upside the head and recommend they look it up) . However these scores are best interpreted alongside a real diary of events as the pain has a better fit to stress than to illness in almost all cases. This evidence is routinely used, but what it shows in alternative therapy is what one would expect- a short duration of effect tailing rapidly. In chronic pain that is frankly useless. Its worse than nothing, its the sparrow in the mead hall.

“Bruce: Perhaps you are too accustomed to preaching to the choir and don’t realize that no logical case can be made if the premise is false.”

Oh yes, a bunch of people who agree must be the ones who are wrong. You, poor single misunderstood person with a line of logic that no one can follow is the persecuted one. We have addressed your premise many times over… and over…. and over.

If the choir is singing the song of logic, then I will preach on brother!

Incitatus: Yeah, cost is an issue. From what I understand, some insurance will only pay for x number of visits UNLESS there is functional improvement, in which case they would pay for more. Agree that chiropractors should not be treating medical conditions. My experience is that, for low back pain, since the condition is self-limited often anyway, a few chiropractic visits often do the trick. When you get into the issue of chronic pain, it’s real complicated, but I don’t think chiropractic has much of role here beyond x number of visits unless there is functional improvement. Sometimes there is and sometimes not.

Bruce: I’m not arguing logic, of course. I am arguing against logic based on false premises (patients don’t know when their pain is still there, patient report of pain relief cannot be trusted, chiropractors use “magic” to treat low back pain, etc.). When I contend that something (a premise) is “wrong” and some here object to the use of that word and bounce it back to logic, they are unresponsive to the issue which is the false premise.

Steve12: Do you, Steve12, know what the components of chiropractic treatment are other than those in physiotherapy? he asked for a 5th time.

When chiro and physiotherapy treat back pain, they use similar if not identical modalities. I have never said, no do I believe, that the profession of chiro with all its beliefs is “identical” to physiotherapy.

“Steve12: Do you, Steve12, know what the components of chiropractic treatment are other than those in physiotherapy? he asked for a 5th time.”

How many times can I say that I DO NOT KNOW?
I DO NOT KNOW.
I DO NOT KNOW.
I DO NOT KNOW.
I DO NOT KNOW.
I DO NOT KNOW.

YOU are the one who refers patients to them. SO I AM ASKING YOU.

“When chiro and physiotherapy treat back pain, they use similar if not identical modalities. I have never said, no do I believe, that the profession of chiro with all its beliefs is “identical” to physiotherapy.”

“I’m not arguing logic, of course. I am arguing against logic based on false premises (patients don’t know when their pain is still there, patient report of pain relief cannot be trusted, chiropractors use “magic” to treat low back pain, etc.).”

And we have addressed every single one of your “false” premises and spelled out exactly why they are either not false or are red herrings.

Again… and again… and again…

Once we knock out one, you trot out one of the others, then we knock that down and you run to another… until you come back to the first yet again as if we have not addressed it before. Sometimes you do it all in one post.

I keep getting drawn in because I hope beyond hope you will see where you may have gone wrong… but I must remind myself what I said to Hoss and his response.

Bruce: And lest we forget, the wrong premise that evaluating the treatment of a disease with objective criteria for better and not better (asthma) is the same or even in the same ballpark as evaluating the treatment of low back pain which has no objective criteria.

Steve12: As I said many times, “I don’t know what components chiropractors use other than the ones I listed. I don’t know if there are any, and, if there are, what they are. You are convinced there are others, so you tell me what they are and we can discuss.”

So if NEITHER ONE OF US KNOWS whether or not there are any modalities that chiropractors use other than the usual (heat/ice, massage, manipulation, etc.), then why do you keep asking the question?

Patients get referred to chiropractors for treatment of low back pain. Period. As I said many times before, the chiropractors do what other practitioners do for low back pain, and that is the reason why they are successful in helping to relieve low back pain. Because they use the same modalities as others. Can’t make it any clearer than that

Bruce: Your success in knocking down my claim of false premises is non-existent. I can sense your frustration in failing to slip in the false premises that you have created (patients don’t know when they have pain, successful treatment of asthma is in the same ballpark as successful treatment of low back pain, chiropractors use magical modalities to treat low back pain) and make your case. Unfortunately, that’s not how it works. Your premise cannot be false, otherwise your conclusion will also be false.

No you haven’t.
You’ve made no response to the the second point I made regarding placebo controlled trials that show there are patients who say their pain has improved after using treatments that have been shown by placebo controlled trials to not work.

I guess that you either do not understand that point or you are trying to avoid cognitive dissonance.

“And lest we forget, the wrong premise that evaluating the treatment of a disease with objective criteria for better and not better (asthma) is the same or even in the same ballpark as evaluating the treatment of low back pain which has no objective criteria.”

And again, you fail to see the point that has been pointed out many many times before. I am not rehashing it.

“Your success in knocking down my claim of false premises is non-existent.”

I said “knocking out” in reference to proving they are not actually false premises or are red herrings.

2. “In other words, patients say their pain is better using treatments that do not help to reduce pain.
They are saying their pain is better when it is not better.” Don’t you see that this does not follow? What you are saying is that the patient uses a treatment that you think does not help to reduce pain or that has not been shown to reduce pain, and then when he reports pain relief, you are saying that he in fact still has pain. How can you possibly know that he still has pain if he says he doesn’t? Really. Think about it. Where are you getting the information and how are you evaluating that he still has pain?

“So if you were his doc and he went to have a photon treatment for pain and came back and said he was pain free, would you continue to treat him for pain that he doesn’t have?”

Seems pretty clear to me. If the patient reports pain relief after using a treatment that “you think does not help to reduce pain or that has not been shown to reduce pain,” and the patient reports pain relief, then the placebo effect has no doubt kicked in. This does not mean that there is no pain relief. It means that his pain relief came from something else other than the treatment. The pain is no longer there. You have no information at all that says he still has pain when he says he doesn’t.

Bruce: A false premise is still a false premise whether you recognize it or not. I pointed out several false premises which you obviously don’t recognize. Maybe if you weren’t so biased against chiropractic and hadn’t already made up your mind, you would be more likely to recognize a false premise when you use it. Or maybe not.

Patients get referred to chiropractors for treatment of low back pain. Period. As I said many times before, the chiropractors do what other practitioners do for low back pain, and that is the reason why they are successful in helping to relieve low back pain. Because they use the same modalities as others. Can’t make it any clearer than that

Chiropractors doing what anyone else does to relieve lower back pain means that they stumbled on a condition that is indeed caused by vertebral joint mis-alignment, and responds to their type of manipulation. This does not mean the ideas behind chiropractic are valid. A stopped clock indicating the correct time twice a day is broken, not exhibiting an alternative, equally valid way of timekeeping.

Chiropractors do not limit themselves to treating lower back pain, even if regular MDs only refer patients with lower back pain. Using chiropractic to treat anything else than lower back pain is dangerous, and anyone who really cares about their patients would not expose them to treatments based on medieval vitalistic concepts.

Chiropractic, like osteopathy, homeopathy, faith healing, shamanism, reiki etc. is nonsense. This does not mean these practices do not comfort people — they do, but that doesn’t mean they are anything else but nonsense.

Bruce: “And we have addressed every single one of your “false” premises and spelled out exactly why they are either not false or are red herrings.”

Try reading again all the false premises that have been propounded (analogy of treatment of asthma, pain even when patient says no pain, magical chiropractic without description of the magic) and see which of those holds up to scrutiny. You don’t recognize that these false premises are used over and over.

Starting from your conclusion — chiropractic does not work and cannot work — and trying to work back to formulate a logical argument is always a bad way to go about it. One winds up saying things like the patient says he has no pain but he really does have pain. Things that make no sense.

Joe
What you’re asserting as “false premises” are proven through several individual lines of arguments. Do you really need me to copy and paste each argument that concludes with, what you’re calling, “false premises”. I’ll dumb it down more for the sake of reading comprehension. You’re calling conclusions to arguments premises.

Hoss: Once again you do not answer the challenge, which was, if you remember, to “tell me how you know a particular patient who says he has no pain actually does have pain.” You obviously did not read what you cited, did you?

All the citations, not all of which were placebo studies, indicated as a criterion “pain relief” as reported by the patient. They did not say that patients who reported pain relief actually did have pain relief, because that is impossible to evaluate. They reported pain relief even among those who received placebo, and they took it as a given that placebos relieve pain. Unlike you.

So I challenge you again: demonstrate how a patient can report pain relief and yet you know that there was no pain relief.

The second challenge was to show me how the treatment of asthma which has objective measurements can compare with treatment of pain which has no objective measurements.

And don’t forget to show me how you know that a patient who reports pain relief after chiropractic actually still has pain.

Joe
You’re slippery. You seem to be stuck on something I’m not saying.

“[D]emonstrate how a patient can report pain relief and yet you know that there was no pain relief.”

You’re forgetting this is in the context of treatment and efficacy. You’re changing the scope. If a subject reports pain relief from treatment, the treatment did not necessarily work. A subject can report pain relief even when treatment is ineffective. To demonstrate this, I sent the Pubmed link of efficacy studies containing placebo controls with subjects in the placebo groups reporting pain relief.

“The second challenge was to show me how the treatment of asthma which has objective measurements can compare with treatment of pain which has no objective measurements.”

I’m not sure what you’re talking about. You seem to be claiming that the asthma example isn’t relevant because it’s in a different category than what is being argued. The effect the asthma example was demonstrating occurs in both categories. Any trial with this effect, regardless of measurement type, is relevant.

“And don’t forget to show me how you know that a patient who reports pain relief after chiropractic actually still has pain.”

I have a problem with your question yet again. The question needs to be in the context of efficacy. Reported pain relief does not mean chiropractic works. It is a fallacy to say that chiropractic works because people say they are better. The chiropractic experience is a combination of physiotherapy and placebo effects. Chiropractic has no set standards and has a wide range of methods.

Currently chiro is on a spectrum. At its best chiro mirrors physiotherapy, and at its worst is fraud based on bullshit justified through placebo effects. Medical science should and does separate the effective from the ineffective.

Hoss: I’m not changing anything. The false premise which has been stated many times is that patients report pain relief when there is no pain relief. This is ludicrous, as several people have pointed out. When the patient says they are pain-free, they are free of pain. The false premise has nothing at all to do with the cause of the pain relief. Instead, the contention here has been that there is no pain relief — indeed, it is impossible for there to be pain relief with certain treatments — regardless of what the patient reports.

You are being a little slippery yourself. When you say that the patient “reports” pain relief, do you agree that they really do have pain relief or do you think they are still in pain?

A patient can report pain relief and have pain relief regardless of the treatment. And the studies you cited make that clear. A patient can go to a chiropractor and experience pain relief. The contention of some here is that the patient is deceiving himself into thinking his pain is gone when it is still there. Ludicrous.

Regarding asthma, the contention by a couple of people here was that patients “deceived” themselves into thinking they were better when the objective evidence showed they were not. It was contended that this “deception” occurred even in asthma. To equate this with the treatment of low back pain is not a valid comparison because asthma has objective parameters which can be used to determine better or not better. Whereas low back pain is a purely subjective entity where the ONLY determinant of better or not better is patient report. So if a patient has low back pain and feels better after treatment, they ARE better. Whereas a patient with asthma might be feeling symptomatically better while the objective parameters disagree. The objective and subjective usually catch up to each other. Big difference between the two entities (asthma and low back pain) and they are not comparable.

Regarding chiropractic, when a patient reports pain relief following chiropractic treatment it is perfectly reasonable to conclude that the chiropractic experience helped him to feel better. The reason is that chiropractic uses the same modalities as other practitioners, and these modalities have been proven to be effective. Whether or not people like the chiropractic teaching about vaccination or whatever, chiropractic works on low back pain. Once again, the contention from some was that the patient reported feeling better but really didn’t feel better.

Whether or not people like the chiropractic teaching about vaccination or whatever, chiropractic works on low back pain.

No, chiropractic never works, there just happens to be an instance of where an invalid concept leads to one effective treatment. That doesn’t add one jot of validity to the concept, and shouldn’t be a justification for the recognition of chiropractors. Anything they do is done by physiotherapists.

If someone reports they have no pain, then they are reporting they have no pain (it might not necessarily mean the pain is gone because they might just want you to go away more than the pain). Even if the pain is gone, this does not mean the cause of the pain is gone or that anything about the underlying condition has changed. Pain is subjective by your own admission and you seem to want to hold on to the reporting of pain as being the ONLY measure of the success of a treatment.

We show you evidence that people can misreport their own condition on something that is objectively measurable and you dismiss it because pain is not objectively measurable… surely this should make you doubt measuring pain as an indicator for success of a treatment? If anything dulling the pain but leaving the underlying condition can be even more dangerous as it leaves the patient with a sense of security and they end up doing things that make the condition worse!

You then defend Chiros because they have one treatment that works amongst a world of woo, you would rather they go there than to a physio or a science based practitioner who can do exactly the same thing and more and not run the risk of them being peddled snake oil…? The referal to a Chiro is not wrong (per se) in this case, but it is by far the lesser choice.

Okay, I’m going to say right now that am pain free: I am pain free.
So you’re going to claim that because I say I am pain free, I am therrefore free of pain.
But, in fact, that is actually not the case.

“This is ludicrous”

This is what is ludicrous:
When the patient says they are pain-free, they are free of pain.
I hope I have demonstrated why.

” A patient can go to a chiropractor and experience pain relief. The contention of some here is that the patient is deceiving himself into thinking his pain is gone when it is still there. Ludicrous.”

Nobody said that.

What we have said is that some patients who have seen a practitioner for pain relief can report that they have had pain relief when they don’t. And we gave reasons why some patients might report that they have pain relief when they don’t. This incudes self-deception, being deceived, lying for whatever reason including a desire to not hurt the feelings of the practitoner or to please the kind and attentive practitioner, lying as a ploy to avoid having to make another appointment because this treatment hasn’t worked and he wants to try somethng else or see another practitioner.

It is ludicrous to say that when the patient reports they are pain-free, they must therefore necessarily be free of pain.

I just demonstrated in my very last post how ludicrous that statement is.

And everyone here would have a similar personal anecdote that demonstrates how ludicrous that statement is. I mean, really, who are you trying to kid?

“If someone reports they have no pain, then they are reporting they have no pain (it might not necessarily mean the pain is gone because they might just want you to go away more than the pain)”

Good way to put it.
I have borrowed your word “reports” to put in place of “says” in my last post.
But I doubt if it will make any difference to Joe’s understanding – or that he will admit if, by chance, he does suddenly see the light.

(Actually, at this very moment Joe could be just be reporting that he thinks we are wrong, whilst actually having realised some time ago that we are right!)

Steve12: As I said many times, “I don’t know what components chiropractors use other than the ones I listed. I don’t know if there are any, and, if there are, what they are.”

That wasn’t so hard, was it?

So as far as you know chiro=physiotherapy, or at the least you don’t know how they differ. I think chiros and PTs would agree that they are different, and that chiros have positied mechanisms that science has rejected, like working with energy in keeping with ‘vitalism’.

And as I said earlier, if you don’t know the difference between two approaches (and now we know that you do not), and some literature has shown both to be equally effective, why wouldn’t you choose the one that is subject to scientific inquiry? If for no other reason than it has a chance to improve?

Steve12: “So as far as you know chiro=physiotherapy, or at the least you don’t know how they differ.” What we do know is that they use the same proven modalities of treatment and their patients recover. That’s not good enough for you? They also have to vote Democratic to make them pure enough to treat your lower back pain?

BillOpenthalt: “Anything they [chiros] do is done by physiotherapists.” I agree. And you pay for both.

Bruce: “Even if the pain is gone, this does not mean the cause of the pain is gone or that anything about the underlying condition has changed. Pain is subjective by your own admission and you seem to want to hold on to the reporting of pain as being the ONLY measure of the success of a treatment.”

Pain relief IS the only measure of success in treatment of routine low back pain. If that is the patient’s goal — to be relieved of this low back pain — and the patient gets relief of pain, then the patient has achieved his goal. Do you think there is ANOTHER measure of success when treating low back pain? If so, what is it? And what “underlying condition” are you talking about?

“You then defend Chiros because they have one treatment that works amongst a world of woo.” Ah, have we finally come to the conclusion that chiropractic works? Maybe it’s the “no-nukes” posters on the walls of their office that bothers you?

BillyJoe: “This is what is ludicrous: When the patient says they are pain-free, they are free of pain.” How do YOU know that? How would YOU ever know that when a particular patient tells you he is pain-free, he is actually having pain? Seriously, how could you ever know that? And, more to the point of reality, what would you do about it if you were the patient’s doc and the patient tells you they have no pain? Treat him?

“What we have said is that some patients who have seen a practitioner for pain relief can report that they have had pain relief when they don’t.” I know you have said that, and it is a false premise. The question remains, how would the practitioner confirm that the patient is still in pain? What objective measurement do you have that shows you that the patient is really still in pain when they say they are not?

I think this is critical to your understanding and personal growth to realize that when a patient states that a symptom is gone (headache, low back pain, itch, fatigue), there is no objective way of measuring that this report is false. Same as if the patient comes in complaining of a symptom. If there’s no objective way of determining whether the symptom is there, one may want to treat the patient UNTIL the patient reports that the symptom is gone. If the treatment is aimed at relief of symptoms and the patient states relief of symptoms, then the treatment is discontinued because the goal is met.

OK Dr. Joe, I’m comfortable agreeing that the gold standard for measuring low back pain is self-reports. Standardized and validated self-report rating scales would be particularly valuable, for measuring this as scientifically as possible.

It’s still not clear to me what value chriro as a profession is adding to the mix, if anything. And you don’t seem so clear on this question either. If we can agree chiro is generally awash in voo-doo style pseudo-scientific hogwash, does it matter that it occasionally maybe kinda sorta helps some people? Don’t you agree medical dr’s should be practicing and advocating science-supported and evidence-based medicine?

“What we do know is that they use the same proven modalities of treatment and their patients recover. That’s not good enough for you? ”

This is just ridiculous. I ceded long ago that chiros have an effect – I just want to know how. So this is silliness. As people have tried to communicate to you 10000x, what’s of interest is HOW. I see the problem now. It’s not that you don’t understand how chiro works. It’s that you don’t understand what “how” means.

And per the usual, you dodged my Q above:

“What we do know is that they use the same proven modalities of treatment and their patients recover. That’s not good enough for you? They also have to vote Democratic to make them pure enough to treat your lower back pain?”

“They also have to vote Democratic to make them pure enough to treat your lower back pain?”

Oh boy – a politico. I love how politicos are itchin’ to inject their politics into everything – no matter how off topic. I should have seen this coming from your “I don’t know anything about global warming and cannot discuss the lit – yet have strong opinions!” bit.

I though conservatives would see chiro as fru-fru. Most of my chiro attending friends are liberals…

OtherJohn: “Don’t you agree medical dr’s should be practicing and advocating science-supported and evidence-based medicine?” Yes, I do. My concern is really not so much with “chiro as a profession.” If it works and some patients like it and get results from it, then I guess I have to go with that rather than worry about how the profession operates. If I knew a particular chiropractor was doing a lot of unnecessary stuff or if I knew that a particular dermatologist was doing unnecessary stuff, then I would probably recommend against the use of that person.

Steve12: Brick wall. You want to know how chiropractors have an effect and I tell you it is because they use the common modalities that others use in the treatment of low back pain. That is the “how.” How can I make it clearer than that?

The reference to Democratic was meant to indicate that other side issues such as a practitioner’s belief system have nothing to do with whether their treatment works. I could have used Mormon or Black Panther or vegan. Come on, lighten up.

Joe
A majority of my arguments against your position have been about efficacy.

“Regarding chiropractic, when a patient reports pain relief following chiropractic treatment it is perfectly reasonable to conclude that the chiropractic experience helped him to feel better.”

That is not a logically valid conclusion. Logically, you cannot necessarily conclude that a person reporting relief after a chiropractic treatment is due to chiropractic treatment and not from placebo effects. I suppose you could make that claim if you include placebo effects in the “chiropractic experience”. But if a treatment has the same effects as placebo, then the treatment is ineffective. I also don’t see the point of saying that a person can report feeling better after placebo, if you are indeed mixing the placebo effect into the “chiropractic experience”.

You need to pick a less contentious treatment than chiropractic to make your points so we can move this discussion along.

Dr. Joe, thanks for responding and clarifying. Hoss as well as many others are also correct, that you shouldn’t be attributing possible improvements to the “chiro experience” unless and until it is scientifically validated to say so, because of the confusion this causes readers or patients. We want to give the most accurate and scientifically validated information to patients regarding efficacy of treatments, and on this count chiro seems to be sorely lacking and mired in pseudo-scientific nonsense. You see our concern here?

I think we can all agree this is a tricky/thorny issue for say primary care physicians dealing with patients that desire to use chiro, and that may have positive experiences with it in the past. Especially for patients that may have tried lots of different treatment modalities for pain, to no avail. This concern goes well beyond chiro into the broad realm of “alternative” medicine. Not sure there is a simple answer here, although I have seen others’ comments and good ideas regarding how to deal with such situations in the clinic.

Hoss: Make sure you use my whole quote otherwise one might get the wrong impression.

“When a patient reports pain relief following chiropractic treatment it is perfectly reasonable to conclude that the chiropractic experience helped him to feel better. The reason is that chiropractic uses the same modalities as other practitioners, and these modalities have been proven to be effective.”

No one is talking about “placebo effects.” Where are you getting that? What we’re talking about is the known effects of the usual effective treatment modalities that chiropractors, physiotherapists, osteopaths, etc., use.

TheotherJohnMc: I purposely did not break down the chiropractic experience because I realize that the reason it works is a combination of treatment modalities. The other reason is to demonstrate that some people disdain chiropractic because of what they see as unscientific teaching. Chiropractic works and some chiropractors teach unscientific things. Can’t we do both?

And you are right that primary care docs have this issue to deal with. They know that what chiropractors do works, and they know that their patients may have had positive experiences from chiropractic care. But they may want to shield their patients from the fluff that sometimes goes with it.

Joe
“No one is talking about “placebo effects.” Where are you getting that? What we’re talking about is the known effects of the usual effective treatment modalities that chiropractors, physiotherapists, osteopaths, etc., use.”

“Steven: Symptom relief is defined by the person experiencing the symptom. If the patient goes to a chiropractor and comes out with symptom relief, they consider that the chiropractic experience “worked.” Whether it’s the manipulation or attention or massage or some placebo effect added on, the experience and the care they got at the chiropractor contributed to their improvement. They know that. I don’t think it’s necessary to break it down into the components of the experience, like massage works and heat works and attention works but manipulation doesn’t work. It’s all a package and an experience that many patients find beneficial.” DrJoeinCAon 09 Mar 2014 at 12:48 pm

Are you sure no one is talking about the placebo effect being part of the chiropractic experience?

“When a patient reports pain relief following chiropractic treatment it is perfectly reasonable to conclude that the chiropractic experience helped him to feel better. The reason is that chiropractic uses the same modalities as other practitioners, and these modalities have been proven to be effective.”

Just because a subset of treatments of a larger set of treatments has been proven efficacious does not mean all of the large set of treatments are efficacious. Chiropractic does not only use treatments that have proven efficacy. This is one of the main reasons you need to stop using it as an example. Even if we stipulate all the treatments in chiropractic were proven efficacious, there are still some people who would not benefit from the treatment but would experience placebo effects. Perhaps you should modify your example so chiropractic is effective for everyone. I’d finally agree with your logic, but disagree with your premise and conclusion(yet again).

Hoss: What I said: “Or some placebo effect ADDED ON.” That means added on to the other stuff that works. Of course, there are non-clinical things about the experience that have beneficial effects — clean waiting room, pleasant and attentive staff, etc. But this is true for any treatment experience from any provider, not just chiropractic.

“Even if we stipulate all the treatments in chiropractic were proven efficacious, there are still some people who would not benefit from the treatment but would experience placebo effects.” How could you ever know that? What does that even mean? Not everyone benefits from efficacious treatment, but you have to be in pretty severe denial to deny that a person who gets relief following treatment which is efficacious did not in fact get the relief from that treatment.

“when a patient states that a symptom is gone, there is no objective way of measuring that this report is false”

I see you have backed away from your original statement which was…

“when a patient states that a symptom is gone, it is gone”

All I have been saying all along is that the second statement above is incorrect.
It seems you now agree.
Congratulations.

Now you need to admit that it is possible to objectively prove patients’ report of symtoms are wrong.
Insurance companies do it all the time.
A patient reports his pain is so bad he can’t even wash his car.
The insurance company videos him washing his car with no apparent restrictions in movement and no other objective signs that he is in pain.
In the doctor’s office, patients can also be coaxed into doing things they claim they cannot do because of pain. The patient comes in hardy able to walk and, after a friendly diverting chat, he happily leaps up onto the couch for his examination without apparent restriction of movement or other objective evidence of pain.

“Steve12: Brick wall. You want to know how chiropractors have an effect and I tell you it is because they use the common modalities that others use in the treatment of low back pain. That is the “how.” How can I make it clearer than that?”

Brick wall? How many times can I say that the mechanisms (the “how”) we’re asking about are those specific to chiro – i.e. not overlapping with PT? 1000?

Me: “How does chiropractic work aside from those techniques that are also used in PT?”
You: “It works by the mechanisms it has in common with PT.”

YOu finally answered me by telling us you don’t know. ONly took 200+ posts, but we got there…

My Q (appeal #3):
if you don’t know the difference between two approaches (and now we know that you do not), and some literature has shown both to be equally effective, why wouldn’t you choose the one that is subject to scientific inquiry? If for no other reason than it has a chance to improve?

BillyJoe: You really are bringing up malingering and insurance fraud to “prove” that patient report of having symptoms is a lie?

Isn’t what you have been saying all along that patients are “incorrect” when they say their pain is gone, when they say their symptoms are gone? How about proving that when a patient says he has NO pain, that he is incorrect? Have you come up with that one yet? That’s what’s making this drag on so long. You have been corrected several times and are still unable to prove what you started with, that patients are “incorrect” when they say their symptoms are gone. And you also have not figured out how you would “treat” this patient who is incorrect about saying his symptoms are gone.

Yes, when a patient says a symptom is GONE and is not lying (really?) there is no objective way to say that he still has the symptom.

Steve12: Whatever you are smoking, pass it around. You obviously are not reading what has been said. I tell you several times that chiropractic works by the mechanisms it has in common with PT — that is “how it works” — and you interpret that as “you don’t know.” Interesting.

And for the 10th time, you or the patient can choose either because they are EQUALLY EFFECTIVE because they use the same mechanisms of treatment. Do you not understand that yet? They are equally effective because they use the same treatment. That’s what counts, not what they read or have on their walls or smoke.

BillyJoe: Before you start using insurance fraud along with asthma, let me explain to you why that analogy doesn’t work either.

Insurance companies don’t give a crap whether or not an employee is in pain. People work with pain all the time. What the companies do care about is when an employee states that he cannot do his job. Say the job is to lift 20 pound bags all day and the employee says he cannot do that. When the insurance company then videos the employee and sees that in fact the employee can lift 20 pounds all day, then there is OBJECTIVE evidence that the employee’s claim that he is unable to work is proven fraudulent.

Fraudulent claims are not prosecuted because the employee says he is in pain because there is no objective way of knowing whether or not that is true. It’s a symptom and is therefore subjective. Fraudulent claims are prosecuted when the employee claims he cannot do an objectively measurable task and the evidence is otherwise.

I see you honed in on the insurance fraud reference.
(It seems you don’t think insurance companies look for objective evidence to bring before a judge)
But you ignored this bit…

“In the doctor’s office, patients can also be coaxed into doing things they claim they cannot do because of pain. The patient comes in hardy able to walk and, after a friendly diverting chat, he happily leaps up onto the couch for his examination without apparent restriction of movement or other objective evidence of pain.”

And, of course, if they report that they are no longer in pain, patients should be able to leap up on the couch without much restriction in movement. If they can’t, if they grimace and struggle, if they clutch their back, if they collapse to the floor you can safely assume their pain has not resolved.

“What the companies do care about is when an employee states that he cannot do his job*. Say the job is to lift 20 pound bags all day and the employee says he cannot do that*. When the insurance company then videos the employee and sees that in fact the employee can lift 20 pounds all day*, then there is OBJECTIVE evidence that the employee’s claim that he is unable to work* is proven fraudulent.”

Nevertheless, I have proven to you that your original statement is false to such a degree that you’ve had no choice but to finally agree that it is false. As I said, congratulations for finally getting there. But here’s just one more step to go but, if it’s going to take another few hundred posts, count me out.

You see a patient for a routine check up and he can easily touch his toes.
He returns with back pain and he can barely touch his knees.
You treat him.He reports that his pain is better.
You check his mobility.
He can barely touch his knees without grimacing.His pain is objectively not better.

BJ, using the word “objectively” in that last sentence doesn’t seem accurate. I think that’s Dr. Joe’s point, and I don’t think he would deny patients can lie, misunderstand, or not be aware of their own sensations….but I’m not aware of any objective measures of pain that can replace the “gold standard” of subjective report.

“I don’t think he would deny patients can lie, misunderstand, or not be aware of their own sensations”

DrJoe initially stated that when patients report that they have pain, they have pain. When I offered several situations where patients report they have pain when they don’t have pain, he continued to repeat his claim that when patients report that they have pain, they have pain. Finally, it became obvious even to him that he could no longer defend that claim and, therefore, he retreated to a watered down version of his initial claim by saying that when a patient reports that they have pain, there is no objective way of measuring that this report is false. So now, I have offered him several situations where even this watered down claim is false.

“but I’m not aware of any objective measures of pain that can replace the “gold standard” of subjective report.”

That is not what we are arguing.
Though I have no doubt that DrJoe is capable of watering his claim down still further to something like this version.

In any case…
DrJoe’s argument is that if patients report that their pain is better after a particular treatment, then it is legitmate to refer patients for that treatment. My point is that patients can report that their pain is better when it is not better and, additionally, that some patients report they are better using treatments have been shown by placebo controlled trials to be ineffective.

I completely agree Dr. Joe should be reconsidering a claim such as “if patients report that their pain is better after a particular treatment, then it is legitmate to refer patients for that treatment”. This is a problematic statement, for the many reasons already discussed by everyone.

And his recent statement to steve12: “chiropractic works by the mechanisms it has in common with PT” is also problematic because it contains the phrase “chiropractic works” which is sloppy language, likely incorrect, and gives a false impression of the field and its true effectiveness (or lack thereof).

Your point, BJ, about patients being able to report pain is better when it is not, while likely true, is squirrely to actually demonstrate. Your better point, also made by others, is that singular instances of a patient reporting pain relief to a primary doc is scientifically meaningless, and placebo-controlled studies are necessary to actually prove efficacy beyond placebo effects. Totally agree here.

Years ago I went to a chiropractor because I hurt my back.
Here’s what happened-
He would have me lie on a heat pad for a few minutes to relax. Then he would do a massage to get rid of the muscles in spams and so forth. Then he would ‘make the joints move through the range of motion’; this often led to the ‘cracking sound’.
He would then give me an exercise and a stretch to do between visits.

Sonic
What are you trying to conclude from the single data point of you?
Shouldn’t you be looking at all the evidence?
There are also no set standards for chiropractic, although many people within chiropractic are trying to apply science based treatments while getting rid of the crap. Currently there is a spectrum of science based treatment and bs.
Where do you think your chiropractor belonged on the scale?

‘Whatever you are smoking, pass it around. You obviously are not reading what has been said. I tell you several times that chiropractic works by the mechanisms it has in common with PT — that is “how it works” — and you interpret that as “you don’t know.” ‘

You know goddamn well that I was talking about the mechanisms that chiro and PT DO NOT HAVE IN COMMON. And here’s what you said about that:

“I don’t know what components chiropractors use other than the ones I listed. I don’t know if there are any, and, if there are, what they are.

Hence I say you don’t know because YOU say you don’t know.

I have repeated that I am only interested in the mechanisms that chiro and PT DO NOT HAVE IN COMMON too many times for you to be honestly confused anymore. You’re willing to say anything to feel “right”.

**********************

“And for the 10th time, you or the patient can choose either because they are EQUALLY EFFECTIVE because they use the same mechanisms of treatment. “

I refer again to your words above:

“I have never said, no do I believe, that the profession of chiro with all its beliefs is “identical” to physiotherapy.”

“I don’t know what components chiropractors use other than the ones I listed. I don’t know if there are any, and, if there are, what they are.

And my point about modalities that are subject to science being able to improve? Just ignore the points you have no answer for. That makes for an honest discussion.

I have to say – the whole idea that DrJoe can’t understand that I am not asking about mechanisms that PT and chiro have in common is sort of funny simply because of the sheer number of times I’ve said it.

If he’s a 14 year old laughing by his computer, it’s pretty funny.

If he’s an MD that would rather have people believe he can’t understand simple concepts than admit he might need to re-think some of his beliefs it’s very, very sad.

“You see a patient for a routine check up and he can easily touch his toes. He returns with back pain and he can barely touch his knees. You treat him. He reports that his pain is better. You check his mobility.
He can barely touch his knees without grimacing. His pain is objectively not better.”

And then you do what? You ask him whether his pain is better. And he says, well it’s better than it was, no doubt because of your evidenced-based treatment, unless I do this action or that action. Or he says, you know it’s better than it was, but I don’t have time for all this PT nonsense. I have to get back to work. OK, what do you want to do, doc?

Here’s the answer: you do what the patient says he wants to do. If he wants no further treatment, so be it. If he wants more, so be it. But you recognize that he is not SELF-DECEPTIVE. He didn’t DECEIVE himself into thinking he was better. He stated the truth, either that it is better than it was other than some activities or it’s better but not completely gone and he wants to stop treatment anyway.

It is not self-deception. Get that yet?

Speaking of self deception: “[DrJoe] retreated to a watered down version of his initial claim by saying that when a patient reports that they have pain, there is no objective way of measuring that this report is false. So now, I have offered him several situations where even this watered down claim is false.” And your “several situations” is limited to one instance that involves fraud and not a report of “pain” but in fact a report of inability to perform activities that are objectively measurable.

BillyJoe: You still don’t get that when a patient says they have no pain and you want to treat them for pain, the patient will consider you an idiot and run away from you. “No, really, you are dizzy and you do have pain and you are fatigued and you are nauseated, and I know that because I am your doctor, and you couldn’t possibly be feeling better from going to whomever you went to for treatment because I have read scientific studies and those treatments don’t work. So continue to take these drugs and undergo this treatment whether you feel better or not. See me in 6 weeks and let’s see whether your self-deception is any better.”

And you don’t see the inherent foolishness in that approach or get that there is no endpoint to that way of treating patients, huh?

” You still don’t get that when a patient says they have no pain and you want to treat them for pain, the patient will consider you an idiot and run away from you”

Don’t be ridiculous.

“No, really, you are dizzy and you do have pain and you are fatigued and you are nauseated, and I know that because I am your doctor, and you couldn’t possibly be feeling better from going to whomever you went to for treatment because I have read scientific studies and those treatments don’t work. So continue to take these drugs and undergo this treatment whether you feel better or not. See me in 6 weeks and let’s see whether your self-deception is any better.”

Nice story.
But I’ve been talking about what we can know about treatments and patients, not how to manage individual patients.